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DISEASES OF CHILDREN 



DISEASES 
OF CHILDREN 

A PRACTICAL TREATISE ON DIAGNOSIS AND 

TREATMENT FOR THE USE OF STUDENTS 

AND PRACTITIONERS OF MEDICINE 



BY 

BENJAMIN KNOX RACHFORD 

PROFESSOR OF DISEASES OF CHILDREN, OHIO-MIAMI MEDICAL COLLEGE, DEPARTMENT OF MEDICINE OF THE 

UNIVERSITY OF CINCINNATI: PEDIATRICIAN TO THE CINCINNATI HOSPITAL, GOOD SAMARITAN 

HOSPITAL AND JEWISH HOSPITAL: EX-PRESIDENT OF THE AMERICAN PEDIATRIC 

SOCIETY AND MEMRER OF THE ASSOCIATION OF AMERICAN PHYSICIANS. 




NEW YORK AND LONDON 

D. APPLETON AND COMPANY 

1912 



fi 

-r^ 



Copyright, 1912, by 
D. APPLETON AND COMPANY 



Printed in the United States of America 



f CLA327231 
V I . 



TO 



MY WIFE, 



WHO HELPED ME WRITE THIS BOOK 



PREFACE 

In this volume the author has attempted to present to practitioners and 
students of medicine a practical clinical treatise on diseases of infants and 
children. He has but briefly outlined the pathological findings and has 
avoided unnecessary etiological discussions in order that he might, in a 
compact volume, find more space in which to clearly outline the differential 
diagnosis and give in full the treatment of these diseases. 

The diseases of infancy and childhood differ very widely in their 
clinical manifestations and in the methods of their successful treatment 
from corresponding diseases in the adult; the reasons for this are physio- 
logical rather than pathological. The undeveloped organism of the child, 
because of its physiological peculiarities, reacts to the same pathological 
factors very differently from the completed and stable organism of the 
adult. For this reason the author has dwelt in detail on the physiological 
factors of disease in infancy and childhood, and has attempted to make 
practical application of these facts both in the prophylactic and curative 
treatment of these diseases. 

The author acknowledges his indebtedness to Gen. Wm. M. Wherry, 
Dr. M. A. Brown, Dr. Alfred Friedlander, Dr. David I. Wolf stein, Dr. 
Max Dreyfoos, Dr. Frank H. Lamb, Dr. M. L. Heidingsfeld, and Dr. 
Samuel Iglauer for revision of manuscript, and to Dr. W. J. Graf for 
photographic work. 

323 Broadway, Cincinnati. 



CONTENTS 

SECTION I 
THE CHILD 

PAGE 

I. General Hygiene of Infancy and Childhood . . 1 

Chief causes of death in infancy and childhood; gen- 
eral hygiene and care of infants and young children. 
II. Growth and Development . . . . . . 13 

Weight during infancy and early childhood; height of 
child at different ages; head measurements; develop- 
ment of the spine and bony framework; muscular de- 
velopment; the special senses; the nervous system; the 
heat-regulating mechanism. 

III. Examination of the Sick Child 28 

Present illness; previous medical history; family his- 
tory; physical examination; inspection; palpation; re- 
flexes; percussion; auscultation; macroscopic and 
microscopic examination of intestinal discharges; 
tuberculin skin reactions; blood examinations; lumbar 
puncture ; radiography. 

IV. Therapeutics of Infancy and Childhood ... 38 

Drug administration by the mouth; inunctions; fresh 
air; hydrotherapy; hypodermoclysis ; nasal douche; 
stomach-washing ; rectal enemata ; rest-cure ; massage ; 
active and passive exercises; psychotherapy; vaccine 
therapy. 

SECTION II 

THE NEW-BORN 

V. The Care of Premature Infants 62 

Physiological peculiarities of the new-born; incubator; 
padded basket; feeding. 

VI. Diseases of the New-Born . ' 69 

Asphyxia neonatorum ; congenital atelectasis. 
VII. Diseases of the New-Born (Continued) ... 75 

Septic infection; dermatitis exfoliativa; erysipelas; 
ix 



CONTENTS 

tAPTER PAGE 

hemorrhages in the new-born; diseases of the umbili- 
cus; mastitis; Holt's inanition fever. 
VIII. Diseases of the New-Born (Continued) ... 89 

Tetanus neonatorum; icterus neonatorum; occlusion of 
the bile ducts in the new-born; other forms of icterus 
occurring in the new-born; ophthalmia neonatorum. 

IX. Birth Injuries 97 

Cephalhematoma; hematoma; birth palsies. 



SECTION III 

INFANT FEEDING 

X. Milk in Its Relation to Infantile Nutrition . . 100 
Composition; digestibility, and relative importance of 
the various ingredients of milk. 
XI. Human Breast Milk in Its Relations to Infant 

Feeding 107 

Composition of colostrum and human milk; how to 
determine wholesomeness of breast milk; how to 
modify its quantity and quality. 

XII. Breast-Feeding 112 

Principles underlying normal breast-feeding; mixed 
feeding; weaning; the wet-nurse. 

XIII. Food Materials Used in the Artificial Feeding of 

Infants 118 

Clean raw cow's milk; sterilized milk; pasteurized 
milk; peptonized milk; buttermilk; Finkelstein's al- 
bumin milk; skim milk; whey; carbohydrates; pro- 
prietary foods; albumin water; meat preparations. 

XIV. Artificial Feeding 129 

Value of percentage feeding; calorimetric standard; 
principles underlying artificial feeding; home modifi- 
cation of milk; value of carbohydrate and alkaline 
diluents; feeding of difficult cases; laboratory method 
of modifying milk; diet of children as they grow older. 



SECTION IV 
DISEASES OF THE DIGESTIVE SYSTEM 

XV. Dentition 144 

The eruption of the temporary teeth; dentition as a 
pathological factor; permanent teeth. 



CHAPTER 

XVI. 



XVII. 



XVIII. 



XIX. 
XX. 

XXL 
XXII. 

XXIII. 
XXIV. 

XXV. 

XXVI. 

XXVII. 

XXVIII. 



CONTENTS xi 

PAGE 

Stomatitis . 146 

Stomatitis catarrhalis ; stomatitis aphthosa; stomatitis 
rnycosa; stomatitis ulcerosa; stomatitis gangrenosa. 

Other Diseases of the Mouth and Diseases op the 

Esophagus 154 

Bednar's aphthae; perleche; elongated uvula; geo- 
graphical tongue ; tongue-tie ; hare-lip ; esophagitis ; 
periesophageal abscess; branchial cysts. 

Diseases of the Stomach 158 

Acute gastric indigestion; acute gastritis; dilatation 
of the stomach; ulcer of the stomach; acute gastroduo- 
denitis ; congenital hypertrophy of the pylorus ; 
chronic gastritis. 

Etiology and Preventive Treatment of the Intestinal 

Disorders op Infancy 173 

Acute Intestinal Indigestion 183 

Food injuries; fat indigestion; sugar indigestion; 
protein indigestion. 

Enteric Infection 189 

Acute enterocolitis; cholera infantum. 

Chronic Intestinal Indigestion 197 

Chronic enterocolitis; infantile atrophy; marasmus; 
chronic intestinal indigestion in older children. 

Chronic Constipation in Infancy and Congenital Dila- 
tation of the Colon 204 

Intestinal Parasites 210 

Tape-worms ; round-worms ; thread-worms. 

Intestinal Intussusception 219 

Appendicitis 222 

Peritonitis and Ascites 228 

The Rectum and the Anus 233 

Malformations ; polypi ; prolapse ; fissure of anus. 



SECTION V 



NUTRITIONAL DISORDERS 



XXIX. Rickets 237 

XXX. Infantile Scurvy 246 

XXXI. Diabetes Mellitus . . . ' 250 

XXXII. Recurrent Vomiting, Recurrent Coryza and Migraine 251 
Severe acid intoxication with gastroenteritis; recur- 
rent corvza ; migraine. 



Xll 



CONTENTS 



SECTION VI 



CHAPTER 

XXXIIL 

XXXIV. 

XXXV. 

XXXVI. 

XXXVII. 

XXXVIII. 

XXXIX. 

XL. 

XLL 

XLIL 
XLIII. 
XLIV. 

XLV. 



INFECTIOUS DISEASES 

PAGE 

Fever 260 

Typhoid Fever 267 

Malaria 279 

Whooping Cough 287 

Diphtheria . 295 

Influenza . . . . . . . . 308 

Scarlet Fever 315 

Measles 332 

Rubella, erythema infectiosum. 

Variola . . . 345 

Vaccinia; varicella. 

Mumps 357 

Syphilis 360 

Tuberculosis 373 

Acute Articular Rheumatism and Other Forms of 

Arthritis . . , . 402 



SECTION VII 



DISEASES OF THE RESPIRATORY SYSTEM 



XLVI. 



XLVII. 



XLVIII. 



XLIX. 



L. 



LI. 

LII. 

LIII. 



Diseases of the Nasal Mucous Membrane . . . 411 
Rhinitis; epistaxis; foreign bodies in the nose. 

Diseases of Tonsils 417 

Acute follicular tonsillitis; Vincent's angina; chronic 
tonsillar hypertrophy; quinsy. 

Diseases of Pharynx 424 

Adenoids; acute retropharyngeal abscess. 

Diseases of Larynx 429 

Acute laryngitis; edema of the larynx; growths and 
foreign bodies in the larynx; congenital laryngeal 
stridor. 

Bronchitis • . . 438 

Acute catarrhal bronchitis; chronic bronchitis; mem- 
branous bronchitis. 

Lobar Pneumonia 442 

Bronchopneumonia 454 

Pleurisy 470 



CONTENTS 



Xlll 



SECTION VIII 



CHAPTER 

LIV. 

LV. 

LVI. 

LVII. 

LVIII. 

LIX. 



THE HEART 

Congenital Heart Disease 

Acute Endocarditis .... 

Myocarditis and Acute Cardiac Dilatation 

Chronic Valvular Disease 

Functional Cardiac Disorders 

Pericarditis . . 



PAGE 

484 
489 
494 
498 
506 
509 



SECTION IX 

DISEASES OF THE BLOOD AND DUCTLESS GLANDS 

LX. The Blood ......... 515 

LXI. Simple Secondary Anemia . . . . . . 522 

LXII. Pseudo-Leukemia of Infants 524 

LXIII. Chlorosis . 526 

LXIV. Pernicious Anemia 528 

LXV. Leukemia 530 

LXVI. Purpura . . ,531 

LXVII. Hemophilia . .537 

LXVIII. Hodgkin's Disease . 540 

LXIX. Simple Adenitis . 542 

LXX. Status Lymphaticus . . . . . . . 545 

LXXI. Diseases of the Spleen ...... . 551 

LXXII. Diseases of the Thyroid Gland 552 

Sporadic cretinism. 



SECTION X 



DISEASES OF THE UROGENITAL SYSTEM 



LXXIII. 



LXXIV. 
LXXV. 



The Urine 

Lithuria; indicanuria ; hematuria; hemoglobinuria; 

acetonuria; physiological albuminuria; orthostatic 

albuminuria. 

Acute Nephritis 

Chronic Nephritis and Other Diseases of the Kidneys 

Chronic diffuse nephritis; cystopyelitis ; tumors of the 

kidney; hydronephrosis; perinephritis; dislocation of 

the kidney. 



559 



571 

582 



XIV 



CONTENTS 



CHAPTER 

LXXVI. 



LXXVIL 



Diseases of the Genital Organs .... 
Gonorrheal vulvovaginitis; simple vulvovaginitis; 
urethritis; adherent prepuce; phimosis; periphimosis ; 
undescended testicle; hypospadias; enuresis. 

PSEUDOMASTURBATION IN INFANTS .... 



PAGE 

591 



603 



SECTION XI 



DISEASES OF THE NERVOUS SYSTEM 



LXXVIII. 



LXXIX. 



LXXX. 



LXXXI. 



LXXXII. 



Diseases of the Brain 610 

Infantile cerebral palsies; brain tumors; abscess of 
the brain; chronic internal hydrocephalus; meningo- 
cele; encephalocele ; hydrencephalocele ; idiocy. 

Meningitis 626 

Tuberculous meningitis; meningococcus meningitis; 
purulent meningitis. 

Diseases of the Spinal Cord 641 

Anterior poliomyelitis; myelitis; hereditary ataxia; 
spina bifida. 

Diseases of Peripheral Nerves 661 

Multiple neuritis; facial paralysis; progressive mus- 
cular dystrophy. 

General Nervous Diseases 669 

Disorders of sleep; eclampsia in infants and children; 
laryngismus stridulus; tetany in infancy and child- 
hood; nystagmus; epilepsy; chorea; habit-spasm; 
pica; hysteria; headaches; asthma. 



SECTION XII 
DISEASES OF THE EAR 
LXXXIII. Otitis Media and Mastoiditis . 



714 



SECTION XIII 
DISEASES OF THE SKIN 



LXXXIV. Eczema and Other Skin Diseases .... 

Eczema; urticaria; f urunculosis ; erythema multi- 
forme; congenital icthyosis; impetigo contagiosa; 
pemphigus neonatorum; tinea tonsurans; scabies; 
pediculosis capillitii. 



719 



LIST OF ILLUSTRATIONS 



PLATES 

PLATE FACING PAGE 

I. The Moro tuberculin skin reaction 36 '' 

II. Blood picture in dermatitis exfoliativa 79 y 

III. The enanthem of measles (Koplik's spots) 335 

IV. The von Pirquet tuberculin skin reaction 385 / 

V. Scheme of the circulation of the blood in the fetus 483 / 

VI. Blood pictures in von Jaksch's disease, and acute lymphatic 

leukemia 525 



ILLUSTRATIONS IN THE TEXT 

FIGURE PAGE 

1. Effect of electrical stimulation on the spinal ganglion of cat 12 

2. The rate of growth in weight of dull, mediocre, and precocious 

boys and girls 16 

3. Bad position while writing 20, 21 

4. Palpating spinal curvature 32 

5. Percussion and auscultation position 33 

6. Position for lumbar puncture 37 

7. Fresh-air ward 44 

8. Hypodermoclysis 47 

9. Position for nasal douching 48 

10. Stomach-washing 50 

11. Temperature curve showing influence of artificial heat on prema- 

ture infant 63 

12. Padded basket for treatment of premature infants 67 

13. Breck's feeding-tube 68 

14. Schultze's method of artificial respiration 72 

15. Blood chart in dermatitis exfoliativa 79 

16. Umbilical hernia 86 

17. Colostrum 108 

18. Woman's milk 108 

19. Weight chart breast-fed infant 114 

20. Freeman's pasteurizer 121 

21. Weight chart artificially fed infant 136 

22. Thrush fungus 149 

23. Stomatitis gangrenosa, before perforation 152 

xv 



xvi LIST OF ILLUSTRATIONS 

FIGURE PAGE 

24. Stomatitis gangrenosa, after perforation 152 

25. Radiograph, pyloric stenosis 166 

26. Congenital stenosis of the pylorus 167 

27. Congenital stenosis of the pylorus, longitudinal section through 

tumor mass 169 

28. Temperature chart, gastroenteric infection, mild 189 

29. Temperature chart, gastroenteric infection, severe 190 

30. Casein curds 198 

31. Infantile atrophy 199 

32. Taenia saginata 211 

33. Taenia solium 212 

34. Ascaris lumbricoides 216 

35. Egg of ascaris lumbricoides 216 

36. Oxyuris vermicularis 218 

37. Acute peritonitis position 230 

38. Malformations of the rectum 233 

39. Radiograph showing bony deformities in rickets 238 

40. A case of rickets 239 

41. Knock-knees and bow-legs 241 

42. Temperature chart, typhoid fever, child 2 1 /£ years of age 270 

43. Temperature chart, typhoid fever, child 6 years of age 271 

44. Temperature chart, typhoid fever, child 10 years of age 272 

45. Temperature chart, typhoid fever with relapses 274 

46. Temperature chart, malarial fever 282 

47. Temperature chart, pertussis and measles complicated by broncho- 

pneumonia 290 

48. Temperature chart, pharyngeal diphtheria treated with antitoxin. . 297 

49. Temperature chart, laryngeal diphtheria treated by intubation. . . . 298 

50. Chart showing decreased death rate from diphtheria under antitoxin 303 

51. Intubation position 306 

52. Temperature chart, scarlet fever, mild, child 12 years of age 319 

53. Temperature chart, scarlet fever, severe, child 6 years of age 320 

54. Chart showing mortality by age in 5,000 cases of scarlet fever. . . . 326 

55. Temperature chart, measles, uncomplicated 336 

56. Temperature chart, measles, complicated by bronchopneumonia; 

died 337 

57. Temperature chart, measles, complicated by bronchopneumonia; 

recovered 338 

58. Varicella eruption on the fourth day 355 

59. Syphilitic dactylitis 365 

60. "Hutchinson's teeth" 366 

61. Bronchial and other lymph nodes mainly affected in tuberculosis . . 379 

62. Radiograph, enlarged bronchial glands at right hilum 380 

63. Pulmonary tuberculosis with left-sided pneumothorax..... 389 

64. Ileopelvic lymphatic glands . „ „ 390 



LIST OF ILLUSTRATION'S xvii 

FIGURE PAGE 

65. Anterior view of the cecum and appendix 391 

66. Tuberculosis of the spine 392 

67. Position in examination for adenoid growths 427 

68. Retropharyngeal lymph glands 428 

69. Radiograph of foreign body in right bronchus 436 

70. Temperature chart, lobar pneumonia, child 2 years of age 445 

71. Temperature chart, lobar pneumonia, child 4 years of age 446 

72. Temperature chart, lobar pneumonia, child 10 years of age 447 

73. Temperature chart, bronchopneumonia, mild 459 

74. Temperature chart, bronchopneumonia, severe 460 

75. Temperature chart, empyema following pneumonia 473 

76. Temperature chart, empyema 474 

77. Radiograph, pleural effusion in chest 476 

78. James' apparatus for expanding the lung 481 

79. Clubbing of the fingers in congenital heart disease 486 

80. Radiograph of enlarged heart from mitral regurgitation 500 

81. Radiograph of pericarditis with effusion : . 511 

82. Diagram showing blood changes in a ease of purpura hemorrhagica 534 

83. Position in palpating the spleen 551 

84. Typical cretin, age 4 years 554 

85. Same cretin after eight years of treatment 555 

86. Sarcoma of the kidney 588 

87. Genitourinary organs, embryo about five weeks 604 

88. Genitourinary organs, embryo about nine weeks 605 

89. Genitourinary organs 606 

90. Hemiplegia from cerebral hemorrhage 612 

91. Spastic diplegia 614 

92. Idiopathic hydrocephalus 619 

93. Meningocele, encephalocele, hydrencephalocele 621 

94. Temperature chart, tuberculous meningitis - 629 

95. Opisthotonos 633 

96. Temperature chart, meningococcus meningitis 634 

97. Temperature chart, pneumococcus meningitis 640 

98. Temperature chart, acute anterior poliomyelitis 646 

99. Deformities resulting from acute anterior poliomyelitis 647 

100. Quadrupedal gait from acute anterior poliomyelitis 648 

101. Hydrencephalocele and spina bifida 659 

102. Progressive muscular dystrophy 667 

103. Progressive muscular dystrophy 66S 

104. Progressive muscular dystrophy 669 

105. Impetigo contagiosa 731 

106. Ringworm of the scalp 733 

107. Pustular scabies of the hands 736 



PEDIATRICS 

SECTION I 
THE CHILD 

CHAPTEE I 
GENERAL HYGIENE OF INFANCY AND CHILDHOOD 

CHIEF CAUSES OP DEATH IN INFANCY AND CHILDHOOD 

The importance of the proper care of infants and young children is 
emphasized by the terrible mortality which occurs during the early months 
and years of life, and by the fact that this mortality is to a large extent 
due to remediable causes pertaining to general hygiene. Only a few years 
ago it was estimated that about 25 per cent, of all infants living in the 
large cities of the world died during the first year of life, and of these 
deaths from 20 to 25 per cent, occurred during the first month of life. 
After the first month there is a sudden fall in the death rate, and there- 
after it slowly decreases throughout the year. The mortality after the first 
year of life continues high, but gradually diminishes up to the fifth year 
of life. At this period there is a second rapid fall in the death rate, but 
the mortality is still high as compared with that of the young adult and 
is gradually reduced up to the fifteenth year. 

Holt says: "The fundamental causes of infant mortality are mainly 
the result of three conditions, poverty, ignorance and neglect." It is a 
matter of common observation that the great death rate among infants 
in our large cities occurs largely among the very poor. Among the well- 
to-do classes the infant mortality is comparatively slight. 

The chief causes of death during the first year of life are prematurity, 
congenital debility from hereditary causes (syphilis, etc.), malformations, 
birth injuries, septic infection, whooping cough, gastrointestinal and acute 
respiratory diseases. It is evident that a certain proportion of these deaths, 
especially those due to prematurity, congenital debility, malformations and 
birth injuries, cannot be prevented, and yet the loss of life from these 
causes could be materially diminished by the proper medical care of the 
mother before, and of the infant directly after delivery. The mortality 
from septic infection and gastrointestinal diseases has been very materially 

1 



2 GENEKAL HYGIENE OF INFANCY AND CHILDHOOD 

diminished in recent years by the improved hygienic methods for the care 
of the new-born. 

Between the end of the first and the sixteenth month of life the high 
infantile mortality is largely kept up by gastrointestinal diseases, which 
could to a large degree be prevented if it were possible to give these un- 
fortunate infants suitable food and place them under better hygienic sur- 
roundings. 

After the end of the first year of life, gastrointestinal disorders still 
play an important part in producing the death roll; but from the end of 
the first to the fifth year of life influenza, bronchitis, and the pneumonias 
are the most important factors in keeping up the high death rate. These 
infectious respiratory diseases are largely air-borne and are promoted by 
overcrowding and unhygienic surroundings. They could therefore in great 
part be prevented if infants and young children could be separated from 
contagion and given pure flowing air to breathe. 

After the fifth year the ordinary acute infections, such as scarlet fever, 
diphtheria, measles, and whooping cough, keep the mortality of later child- 
hood higher than that of adult life. These diseases are also very much 
more prevalent in the unhygienic, crowded tenements of the poor than 
among the larger, well-ventilated homes of the middle and upper classes. 
The mortality at this time of life could therefore be very materially dimin- 
ished by improving the facilities for the care and isolation of children 
suffering from these infectious diseases. 

The fact that the great majority of deaths which occur among infants 
and young children could be prevented by suitable food, proper care, whole- 
some surroundings and protection from contagions has stimulated city 
health boards and co-operating philanthropical societies to attempt to apply 
these life-saving measures to the children of the poor in our large cities, 
and as a result of these efforts infantile mortality has been reduced from 
26 to 15 per cent., and the mortality among children under five years of 
age has been reduced from 16 to 6 per cent. This remarkable showing of 
the influence which modern hygienic methods have had upon the saving of 
life should stimulate and encourage to still greater accomplishments all 
those interested in this great work. 

GENERAL HYGIENE AND CARE OF INFANTS AND 

CHILDREN 

Care of the New-Born. — From what has been said it is evident that 
one of the most important duties of the physician is to keep children well, 
and this brings us to the consideration of the general hygiene of infancy 
and childhood. 

Soon after birth the umbilical cord, when the pulsation has ceased, 
should be firmly tied with a piece of clean, narrow tape and then cut with 
clean scissors. Following this operation the infant's mouth should be 
washed out and its breathing and heart action carefully observed. If 



CAEE OF IXFAXTS AXD CHILDREN 3 

these be normal and the infant has cried lustily, indicating that normal 
pulmonary inflation has begun, it may be wrapped for a few minutes in 
warm flannels, until the nurse who is attending the mother has the time 
to bathe it. The body of the infant should be gently rubbed with vaselin 
or olive oil to remove the vernix caseosa which covers its body. It should 
then be placed in warm water (temperature 100° F.) and gently washed 
with some non-irritating soap. The stump of the cord should be carefully 
dried and the surrounding parts dusted with talcum or some other powder ; 
it should then be folded in a pad of sterile gauze. This may be done by 
making an opening in the pad through which the cord is inserted. There- 
after it is important to keep the cord, and the dressing which covers it, dry 
until mummification and separation take place; this usually occurs about 
the end of the first week. Following the separation of the cord the umbilicus 
for a few days presents a slightly red surface, over which the epithelium 
is rapidly forming. By the end of the second week the umbilical wound 
should be entirely covered with epithelium and should therefore no longer 
offer a favorable portal for septic infections. Until this occurs the infant 
is to be given one or more sponge baths every day, care being taken through- 
out the whole time to protect the umbilical wound from the wash water or 
other possible sources of infection. When the umbilical wound has healed 
•the infant is to have a tub bath daily, beginning with a temperature of 
100° F., gradually diminishing the temperature of the water as the child 
grows older, but during the first year of life it is not advisable that the 
temperature of this bath should fall much below 90° F. During the early 
days of the life of the infant it is important that the region of the um- 
bilicus be examined without removing the dressing which holds the mum- 
mifying cord. A certain amount of redness in this region is normal, but 
if the parts become swollen, or if the odor from the cord becomes putrid, and 
especially if the temperature of the infant rises two or three degrees above 
normal without apparent cause, the dressing which covers the stump of the 
cord is to be carefully removed and evidences of sepsis looked for. In the 
event that the umbilical wound becomes infected, it is to be treated by the 
method described in the chapter on Sepsis in the New-Born. 

In private practice it is, as a rule, only necessary to carefully wash out 
the eyes of the newly-born infant with distilled water, or a 3 to 5 per cent. 
boracic acid solution. But in the event that the mother has a vaginal dis- 
charge or the child is born in a public institution, it is advisable to instil 
into its eyes a 2 per cent, solution of nitrate of silver and thereafter care- 
fully wash them out with sterile water. During the first days of life it is 
important, especially if the infant be irritable, to have its rectal tempera- 
ture taken twice a day with a clean thermometer anointed with clean 
vaselin. A sharp elevation of temperature during the first days of life 
suggests either sepsis or Holt's (inanition) fever. It is most important 
during the first days of life to note the discharges from the gastrointestinal 
canal. The diapers containing these discharges should be saved for the 
inspection oi the physician, as no one, not even a trained nurse, can ac- 



4 GENEKAL HYGIENE OF INFANCY AND CHILDHOOD 

curately convey to the physician their character. The early dark meconium 
discharges should commence to give way on the third day to milk stools, 
and within ten days or two weeks the fecal discharge should he gradually 
transformed into a soft, yellow, homogeneous mass. The appearance of 
dark, tarry stools after the fifth day is an indication of intestinal hemor- 
rhage (melena), and the presence of mucus, curds and other abnormalities 
may be important early indications of an intestinal condition which needs 
attention. 

Rest and Sleep. — The new-born should sleep nearly all the time, being 
awake but two or three hours in the twenty-four. A young infant, there- 
fore, that spends much of its time awake, fretting and crying, is suffering 
from some condition which should be corrected; hunger, overfeeding and 
indigestion are common causes of fretfulness. As the infant grows older 
it is awake for longer periods of time, but even at one year of age it should 
sleep sixteen hours out of the twenty-four. It is most important during 
its waking hours that the infant should not be coddled and played with. 
It is a very difficult matter to enforce this rule. Most infants in the middle 
and upper walks of life are so surrounded by doting relatives that it is 
difficult to protect them from the incessant fondling and entertaining 
which these devoted and well-meaning people force upon them. As North- 
rup has so graphically pointed out, this is one of the most common causes 
of sleeplessness, irritability and nervousness in infants. For the good 
health and normal development of the infant it should be let alone during 
its waking hours. Properly trained babies are perfectly happy and will 
coo, and play with their toes or some other object which they happen to 
find, never knowing what it means to be taken up, dandled, coddled and 
entertained. 

Fresh Air.- — When, after a few weeks, the infant's nutritional problems 
have been solved and its heat regulating apparatus has been properly ad- 
justed to surrounding conditions, it should be gradually accustomed to a 
temperature cooler than the ordinary house temperature. The windows of 
the room, little by little, should be opened, and the fresh air treatment which 
is to continue throughout childhood, and I might say throughout life, 
should be begun. Depending upon the season of the year, it is to be taken 
out of doors for a short or a long time each day, and windows are to be 
opened so that it shall have fresh and moderately cool air. As the infant 
becomes a child it should then live in pure, fresh air for the whole twenty- 
four hours. Open-air sleeping apartments and wide-open bedroom win- 
dows make this possible until school life begins, and then it is, as a rule, 
necessary that the child should be confined for a few hours during the day 
to the schoolroom, where the air is much less pure than out of doors and 
in homes and sleeping apartments. The transition from the coddling and 
warmth which are necessary during the first days of life to life in the open 
air throughout the twenty-four hours must be gradual. It is only when 
the child has reached the age of three years that it can be readily cared 
for in out-door sleeping apartments during the winter weather in our 
middle and northern states. 



CARE OF INFANTS AND CHILDEEN 5 

The Nursery. — Where it is possible, a large, bright, well-ventilated room 
should be selected for the nursery, as this is to be the indoor home of the 
child during the early years of its life. This room is to be devoted to the 
infant and its necessary attendant, and is not to be a reception room into 
which all interested relatives and visitors are ushered that they may ob- 
serve a wonderfully precocious and beautiful baby. The young infant's 
undeveloped and excitable nervous system should be allowed to develop 
along normal lines and not be kept in a constant state of excitement and 
stimulation during waking hours. The nursery should be free from heavy 
rugs and hangings, as simply furnished as possible, and the air in it fresh, 
pure and free from contagion. As the natural instinct of the infant is to 
put everything into its mouth, its toys and other things with which it 
plays should be of such a character that they may be easily kept clean and 
the infant's surroundings should be such that these playthings will not be 
contaminated when they are dropped by its side. Rubber pacifiers should 
not be tolerated ; their use results in an unhygienic habit which it is difficult 
to break. During the early months of life the infant should spend nearly 
all of its time on a flat mattress. It should not be encouraged to sit up or 
to stand upon its feet until its muscular and bony development are such 
that these procedures will not result in deformities such as curvature of the 
spine and bow-legs. 

Clothing. — The young infant must be rather warmly clad, because its 
heat-regulating apparatus is not sufficiently developed to maintain a normal 
temperature under varying degrees of heat and cold. The laity, however, 
;are thoroughly impressed with the fact that the newly-born infant requires 
more than the ordinary amount of clothing to keep it warm, and the ten- 
dency therefore is not only to clothe the infant too warmly, but to bundle 
it in such a manner as to interfere with the free expansion of its lungs and 
with the exercising of its arms and legs. Rarely indeed is it necessary for 
the physician to prescribe more clothing for the newly-born infant, but, on 
the other hand, he has very frequently to advise the mother to clothe the 
infant less warmly and less tightly, especially during the hot summer 
months. As a general principle, the young infant requires warmer cloth- 
ing than the older child, yet the amount of clothing required must vary 
with the season. During the winter and cooler months of the year the 
ordinary flannel abdominal binder may be used for two or three months, 
and is then to be changed for a knitted band which is held over the shoulders 
by straps and pinned below to the diaper. Long stockings reaching to the 
diaper and a short petticoat and dress, suitable in weight and warmth, 
should be worn. Even in early infancy it is not advisable to have long 
petticoats and dresses, which have to be folded about the feet and which 
interfere with the freedom of action of the legs. The feet protected by 
stockings do not require long swaddling clothes. During the hot months 
of summer, infants, especially those in our large cities, should be very 
lightly clad; on very hot days everything may be removed except the light 
knitted band and diaper. 



6 GENERAL HYGIENE OF INFANCY AND CHILDHOOD 

Contagion. — The careful avoidance of contagion is one of the most im- 
portant principles in the hygiene of infancy. The carelessness with which 
infants under three months of age, even among the well-to-do classes, are 
exposed to influenza, bronchitis, and other catarrhal diseases of the respira- 
tory passages is appalling. It is sometimes difficult to convince even intelli- 
gent mothers that it is worth while to carefully isolate the young infant 
from a prevailing house epidemic of la grippe. It is a well-known fact 
that during the early months of life attacks of coryza, influenza, bronchitis 
and other contagions, which are little feared by the older members of the 
family, may readily develop into serious and even fatal pneumonias. A 
governing principle in every household should be that a sick child should 
be carefully quarantined from the other children in the family, until the 
character of its illness is definitely determined, and if this illness proves 
to be one of the acute infectious diseases the quarantine, so opportunely 
begun, should be rigidly carried out. Whooping cough, influenza, bron- 
chitis, and pneumonia are dangerous diseases in early infancy, and all of 
the ordinary infectious diseases of childhood are likely to run a much 
more severe course in the young infant than they are in the child. The 
importance, therefore, of having a nursery which may serve as an isolation 
room for the well infant in the event of contagion in the family is of great 
importance. 

Excessive Nerve Activity. — As the child reaches school age excessive 
nerve activity (the term including brain work and nerve excitement) con- 
tinues to be a very potent factor in the production of disease. The hygiene 
of childhood, and especially that pertaining to school life, should therefore 
protect the growing nervous system of the child, that it may be relieved 
from all unnecessary strain. 1 

Functional nervous diseases are greatly increased by subjecting the 
immature nervous systems of young children to the almost constant ex- 
citement, nervous strain, and mental activity to which our social order 
subjects them. To counteract these dangers the teachers and guardians 
of the young must be taught that the nervous system of the child differs 
very materially from the nervous system of the adult; they must be con- 
vinced that the child, especially in his nervous organization, is not a little 
man; that his nervous system is structurally and functionally immature; 
that it is excitable, unstable and under feeble inhibitory control; that the 
sources of reflex irritation in the child are many; that the nerve centers 
discharge their force more fitfully and more readily than in the adult; 
that the period corresponding with the onset and establishment of the re- 
productive function in girls is a time when they are especially predisposed 
to nervous disease ; that the brain of the child is far more receptive, imagi- 
native, emotional, and imitative than that of the adult. They should be 

1 The following paragraphs in this chapter are modified from a series of papers 
published by the author in the Archives of Pediatrics in 1893-94, under the title 
"Some Physiological Factors of the Neuroses of Childhood," and were subsequently 
embodied in his monograph on "The Neurotic Disorders of Childhood," E. B. Treat 
& Co., 1905. 



CARE OF INFANTS AND CHILDREN 7 

made aware that these and other physiological peculiarities of the nervous 
system of childhood are made much more potent for evil when they are 
associated with anemia, malnutrition, and chronic diseases, which interfere 
with the physical development of the child. 

In 1892 W. T. Porter, from an examination of 33,500 boys and girls 
in the St. Louis public schools, made a most careful study of the "physical 
basis of precocity and dullness." He demonstrated that children who are 
advanced in their studies are, on the average, heavier, taller and of larger 
girth of chest than less advanced children of the same age. If the ability to 
succeed in school is a measure of mental power, and if successful scholars 
are, as a rule, better developed physically than the less successful, it follows 
that mental ability is, on the average, greater in large children than in 
small children of the same age; in other words, there is in the child a 
physical basis for precocity. 

Porter makes a practical deduction from the law thus established. The 
entrance to any grade in a school is guarded by examination, and the chil- 
dren found in that grade are such as have passed the entrance examination 
and have in this way shown their capacity to do the mental labor exacted 
of them. The greater number of these children are of the same age. The 
work of this grade is, then, normal for this age, and the average height, 
weight, and girth of chest of this age form the physical development most 
often found in children able to do the work of the grade. No child younger 
than the average age of any grade should be permitted to enter it until a 
physical examination has shown that his strength will probably be equal 
to the work, or, as Porter puts it, "No child whose weight is below the 
average of its age should be permitted to enter a school grade beyond the 
average of its age, except after such a physical examination as shall make 
it probable that the child's strength shall be equal to the strain." In de- 
termining this, the relation of weight and girth of chest to height is of 
special importance. Abnormal height is undoubtedly a disadvantage, yet 
such children may be able to do their school work, provided their physical 
development is in proportion to their height. If the contrary is the case, the 
child will be much less able to resist the strain of school life, and should 
therefore have careful physical supervision and be relieved of school work 
when he commences to break down under the confinement and mental 
strain incident to school life. 

In protecting children against the ill effects of excessive brain work 
and nerve excitement, Porter calls attention to the importance of the 
frequent weighing of growing children, and says that the failure of a child 
to make the normal gain in weight is no less important a symptom of 
physical deterioration than persistent loss of weight in the adult. Failure 
to gain in weight over a period of months should lead, therefore, to an 
inquiry into the child's physical condition, into his school tasks, into the 
number of hours he is confined, and into the general hygiene of his home 
and school life. If this rule is followed many children will be saved from 
serious nervous breakdowns. 



8 GENEKAL HYGIENE OF INFANCY AND CHILDHOOD 

It is my belief that if the various grades in our public schools were 
guarded by a physical as well as a mental examination, along the lines 
above indicated, and if persistent loss of weight or failure to gain in weight 
over a number of months were recognized as reasons for a physical inquiry 
into the child's capacity to continue in its grade, the functional nervous 
diseases of childhood would be much less prevalent than they are at the 
present time. With children of good physical development working within 
the limitations of their proper grades, there is no danger that a moderate 
amount of school work will in any way assist in the development of neu- 
rotic disease, provided always that the hygienic conditions of the school, 
especially as to light and ventilation, are good, and provided also that the 
rules of hygiene pertaining to the home life of the child are carried out as 
previously outlined. It is especially important that children who spend a 
great portion of the day in the schoolroom should sleep out of doors, or 
with wide open windows at night. 

The nervous strain and confinement of school life is a very different 
matter with children of poor physical development, many of whom are 
unfortunately precocious. The precocity, however, of this type of child is 
fitful and is not sustained throughout the school year. In every school there 
is a large number of children who are neurotic, poorly nourished, anemic, 
and very materially underdeveloped, and not a few of these are suffering 
from a low grade of glandular tuberculosis. The nervous systems of such 
children are malnourished, and they are therefore not capable of doing the 
ordinary work of their grades, and if they are permitted to continue in this 
work, or if, as is often the case, these children are encouraged to push on 
into higher grades than the one to which their years and strength would 
assign them, disastrous consequences will surely follow, and they will be- 
come the victims of chorea, hysteria and other neuroses. If the medical 
supervision of our schools, which at the present time is concentrated upon 
the prevention of the spread of contagious diseases, could be extended so 
that the physically weak and malnourished child could be referred to the 
family physician or other competent medical authority, in order that the 
question of the advisability of its continuing to do its full school work 
might be determined before a physical or nervous breakdown necessitated 
the withdrawal of the child from the school, then school life would be a 
much less important factor in the production of disease. In dealing with 
children of poor physical development it is not always advisable to remove 
them entirely from school; in some instances it may be wise to have the 
child go to school only during the morning session and to arrange its 
school work so that it may be accomplished without nervous strain. In 
other cases the child may be temporarily removed from the school and 
receive home instruction, which will enable it to keep intellectual pace 
with the children of its school grade. In every such instance the child 
must be kept under observation until its physical development fits it for 
the school grade to which its age and intelligence would assign it. 

It is my belief that our public school system should be so remodeled 



CARE OF INFANTS AND CHILDREN 9 

that all children under twelve or fourteen years of age would be required 
to spend only the morning or the afternoon at school. The present system;, 
which requires that a child during the winter months should spend nearly 
all the daylight hours in a schoolroom, is bad. It is a fact which must be 
evident to every thinking individual that if, instead of spending six or seven 
hours of the day in a schoolroom filled with other children, where the 
hygienic conditions are bad and where physical exercise is largely done 
away with, school children were confined for three or four hours only and 
were permitted to devote the remainder of the day to outdoor play, their 
physical condition would be greatly improved and their mental development 
would not in the least be retarded. 

The reasons, then, are clear why we should not allow a child of poor 
physical development to be pushed to rapid brain development. If we do, 
its nervous system will surely suffer from the strain, and whatever pre- 
disposition it may have to neurotic or other chronic diseases will be greatly 
increased. In dealing with individual cases it is important that the physi- 
cian should know the child's hereditary tendencies. He cannot, of course, 
change the child's ancestry, but he can speak out against the crime of 
pushing children with hereditary physical defects to rapid brain develop- 
ment, and in doing so he may prevent the development of an hereditary 
constitutional weakness into an actual disease. 

In this demonstration of the injury which results to the nervous system 
of the delicate child, from the nervous strain and unhygienic conditions 
of school life, we have a most important warning against the pernicious 
habit of encouraging mental precocity in early childhood. It is a matter 
of almost daily experience to see a poorly nourished and perhaps tuberculous 
child brought forward for the purpose of demonstrating its ''wonderful" 
precocity. The proud mother and overzealous nurse commence the process 
of mental cramming even before infancy has passed into childhood. From 
this time on, children are daily being taught, apparently with the idea of 
destroying their childhood and making of them little men and women. 
Mothers must be told that early precocity is an abnormal condition in the 
human infant, which, if encouraged, may result in actual disease and per- 
manent mental impairment. They must learn that vegetation is the ideal 
life of infancy and early childhood, and that in order to get the best results 
they must look to the physical, and retard the intellectual, development of 
the young child. It must not be taught; it must not be trained; it must 
have plenty of exercise, fresh air, proper food, and, if possible, should spend 
a portion of the year in the country away from the clamor and excitement 
of city life. In the country the older child has more solitude, and must 
depend more upon his own initiative, the importance of which can scarcely 
be overestimated in giving independence of thought and character to the 
future man. 

In the modern well-appointed home the child too often has some one 
to do his thinking, some one to minister to his every want and some one 
to teach or amuse him throughout his waking hours. He has little time 



10 GENEKAL HYGIENE OF INFANCY AND CHILDHOOD 

to himself and a very small portion of his day is spent in play with his 
intellectual equals. Where these conditions exist there is little chance that 
the best possibilities in the boy will be utilized for making the best possible 
man. In 1893 I wrote as follows : "If there is one crying evil common to 
all of our large cities, it is the scarcity of playgrounds for children, and the 
attention of humanitarians should be called to this fact. If our generous 
citizens would pause long enough in the building of hospitals, libraries and 
places of learning to realize there is a field almost totally neglected by 
the humanitarian and one of quite as much importance to the welfare of 
our communities, then possibly a portion of the vast sums of money annually 
spent in this way would be used in providing playgrounds for children. 
These playgrounds should not be covered with beautiful grass plots guarded 
by policemen, but they should be playgrounds in the best sense of the word ; 
places where ball, tennis and all kinds of healthful sport could be enjoyed." 
Since these words were written much has been done in our large cities to 
furnish playgrounds for children, and a movement is now apparently 
spreading over the country, hand in hand with the fresh air movement, 
which is teaching the poor as well as the rich that healthful play in the open 
air for a portion of the day and healthful sleep in fresh flowing air at night 
are much more important to the success of the future man and woman 
than is the number of hours spent in the schoolroom. The day has appar- 
ently dawned when the physiological importance of the physical as well as 
the mental development of children is to be generally recognized, and cities 
and philanthropical societies will be called upon to furnish like opportuni- 
ties for the development of both. 

In the hygienic care of young children it is most important that their 
irritable and undeveloped nervous systems should be protected as much 
as possible from reflex excitation. The profound nervous disturbances 
which may be produced by chronic reflex irritation are not fully recognized 
by those who have the care and teaching of children. Uncorrected eye- 
strain, adherent prepuce and clitoris, chronic adenoid disease, chronic dis- 
ease about the rectum and intestinal irritation may be largely responsible 
for many of the most annoying neurotic disorders of childhood, such as 
headache, night terrors, incontinence of urine, hysteria, chorea, and general 
nervous excitability, any one of which may so interfere with the health and 
comfort of the child as to make it impossible for him to continue in his 
school work. 

The fact that reflex irritation is commonly associated with other factors 
in the production of disease does not in the least diminish its importance 
as a cause of neurotic disease. The removal of the reflex excitant in many 
instances cures the neurosis, even though other important factors remain, 
and not infrequently our best efforts at removal of other factors of neurotic 
disease fail to produce a cure as long as the reflex excitant remains to 
constantly irritate the nerve centers. The explanation of these clinical 
facts is that reflex irritation does not act simply as an excitant in dis- 
charging nerve force from irritable centers, but it also acts in keeping up 






CARE OF INFANTS AND CHILDREN 11 

the irritability in these centers, and if long continued it produces changes 
in the nerve centers, recognizable under the microscope. C. F. Hodge has 
shown that definite changes occur in the nerve cells of the brain and spinal 
ganglia of certain birds and bees as a result of their normal daily activity. 
He compared the nerve cells of sparrows and swallows shot in the early 
morning with the nerve cells of sparrows and swallows shot in the evening 
after a day of hard flight. Experiments of this kind invariably showed 
fatigue changes in the nerve cells tired from the day's work. Hodge also 
found definite changes to occur in the spinal ganglion cells of the frog, 
the cat and the dog under electrical stimulation, and these changes were 
very similar to the changes which he had observed to result from the normal 
daily activity of nerve cells. He also observed that the nerve cell recovered 
much more slowly than it tired, and concludes that : "Individual nerve 
cells after electrical excitation recover if allowed to rest for a sufficient 
tinie, but the process of recovery is slow. From five hours' stimulation 
recovery is scarcely complete after twenty-four hours' rest." In these 
observations we have an explanation of the disastrous consequences which 
result to the immature nervous system of the child from excessive brain 
work, nerve excitement, and chronic reflex irritation, and we have also 
impressed upon us the important physiological fact that these nerve cen- 
ters, if they are to continue to do their best work and functionate in a 
normal manner, must have long periods of rest to recover from the fatigue 
changes which normally result from their physiological activity. It is also 
a fact that the younger the child the more pronounced will be the fatigue 
changes resulting from physiological or pathological activity of its nerve 
cells, and therefore the longer will be the period of rest required to restore 
these nerve centers to a normal condition. 

Reflex irritation, brain work, and nerve excitement are much more 
potent factors in producing functional nervous diseases in the child than 
in the adult, for the following reasons : 

1. The nervous system of the child is more irritable and unstable by 
reason of its incomplete functional development. 

2. The inhibitory control of higher nerve centers over spinal reflex 
movements is feebly developed in the child. 

3. Blood changes associated with anemia and malnutrition are much 
more common allies of reflex factors in producing nervous diseases in chil- 
dren than they are in adults. 

In the above observations we have not only a physiological but also a 
morphological explanation of how and why prolonged brain work, nerve 
excitement and chronic reflex irritation may be such important factors in 
producing all kinds of neurotic disorders in the young child. It follows, 
therefore, that in the hygienic supervision of the child, if these diseases 
are to be avoided, not only all the general hygienic rules which have been 
outlined in this chapter should be followed, but also that the child should 
be carefully examined with reference to reflex causes of irritation to the 
nervous system. It is also important that the physician should recognize 



12 GENEKAL HYGIENE OF INFANCY AND CHILDHOOD 





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Fig. 1. — Electrical Stimulation. — Cats. 
1. Normal. Left spinal ganglion of 1st thoracic pair. Osmic acid. 
2. Stimulated 5 hrs. Mate ganglion to 1. Osmic acid. 
By comparing 2 with 1 is seen the effect of severe work (15 seconds' stimulation to 
45 seconds' rest) for 5 hours, the nuclei becoming darker, shrunken and irregular 
in outline, protoplasm somewhat vacuolated. (C. F. Hodge, Journal of Mor- 
phology, Vol. VII.) 



WEIGHT DUEING INFANCY AND EAELY CHILDHOOD 13 

the fact that the functional development of the male and female genital 
organs which marks the approach of puberty is a source of marked reflex 
disturbance which may greatly predispose to neurotic diseases, and that 
therefore, during this period of life, children should be more carefully 
guarded from the dangers which may result from excessive brain work and 
nerve excitement. Above all, the importance of rest to the nervous system 
should be recognized as the all-important prophylactic measure in prevent- 
ing disastrous results from the above named causes of disease, and that this 
rest can only be satisfactorily obtained by prolonged periods of sleep. Sleep 
is "nature's sweet restorer," and its importance as a preventive of disease in 
childhood cannot be overestimated. It is a most important part of the 
hygiene of infancy and childhood that children from the beginning of 
their lives should, by regulating their daily routine and by placing them 
under quiet surroundings, be made to sleep as much as possible. Even after 
the child has reached the school age it should be sent to bed very soon 
after its evening meal so that if possible it may have eleven or twelve hours 
of sleep. If the habit of long and undisturbed sleep is engrafted firmly 
upon the infantile nervous system, it is, as a rule, easy to continue it into 
late childhood, and if parents could only realize the enormous benefit, physi- 
cal and mental, which its continuance would bring to the child, then they 
would guard and protect the sleeping habit as one of the most important 
heritages of infancy. 



CHAPTEE II 
GEOWTH AND DEVELOPMENT 

Weight during Infancy and Early Childhood.— The increasing weight 
of the infant and young child along normal lines is by far the best indica- 
tion of satisfactory growth and development. There are many signs and 
symptoms which tell of the unsatisfactory development of the child, but 
these for the most part derive their importance from their association with 
a failure to gain in weight, or an actual loss in weight. For example, an 
infant that is making the normal gain in weight week after week on breast 
milk may have curds or occasional mucus in its stools, or the discharges 
from the bowel may vary in consistency, may at times be green in color, 
and the infant may from time to time suffer with attacks of colic, and yet 
all or any of these symptoms pointing to intestinal indigestion are, as com- 
pared with a normal increase in weight, of comparatively little importance. 
In such cases, of course, efforts should be made to correct the indigestion of 
the infant by regulating the life and diet of the mother or by other means 
outlined in the chapter on Infant Feeding; but the fact that there is a 
steady and normal gain in weight, notwithstanding the other symptoms 
that may be present, is of itself sufficient reason for continuing the child 
upon the mother's milk. On the other hand, the stools may be normal and 



14 GBOWTH AND DEVELOPMENT 

the infant may be comparatively contented with its food, sleeping and 
behaving in a normal way in all other particulars except that it is failing 
to gain in weight, and this last indication, outweighing all of the others, 
indicates that the food of the infant must be supplemented or changed. 

Failure to gain in weight in infancy and childhood has the same patho- 
logical significance as loss of weight in the adult. It is not enough that the 
infant or young child should hold its own in weight ; it should, if its nutri- 
tional problems are properly solved, increase in weight in the ratio that is 
normal for its age. Slight variations in weight occur from unknown causes 
in the young infant; the weight may remain stationary for three or four 
days at a time or the scales may record, within a day or two, a gain of three 
or four ounces. These slight variations in weight from day to day should 
be entirely disregarded except perhaps in very ill or in very young or pre- 
mature infants. The child, under ordinary conditions of development, 
should be weighed but once a week during the first seven months of life, 
and thereafter but twice a month during the first year. During the second 
year of life it should be weighed once a month, and during the third and 
fourth years at intervals of every three or four months. By these regular 
weighings, which are especially important during the first year, very valu- 
able information is obtained as to the growth and development of the 
child. Failure to gain in weight for one or even two weeks may not always 
be an indication that the infant is not getting proper food in sufficient 
quantities, since not infrequently the same infant after such a standstill 
may on the same food commence to gain in weight. Too much importance, 
therefore, must not be placed upon the temporary failure to gain in weight 
of an infant that has previously been developing along normal lines. If 
the failure to increase in weight, however, continues longer than three 
weeks, and especially if this symptom be associated with others indicating 
that the child has insufficient or improper food, then prompt steps should 
be taken to find the cause of the trouble and to relieve it. On the other 
hand, it is well to remember that infants, especially those fed upon the 
patent foods, may increase rapidly in weight and yet not be properly 
nourished. The condensed milk and patent food babies, while they are in- 
creasing rapidly in weight, may be suffering very seriously in the de- 
velopment of their osseous, muscular and nervous systems; increase in 
weight on ill-balanced foods may go hand in hand with the development 
of rickets. While it is true that the increasing weight of the infant is the 
most important indication of its satisfactory growth and development, it is 
also true that, if one depends alone upon this sign of normal development, 
many unfortunate mistakes will be made. The increase in weight as a 
sign of growth and development is to be studied in connection with other 
evidences of good health or disease. Weight observations are made, as a 
rule, by the mother or nurse, and too often are they taught to rely exclu- 
sively upon increase in weight in determining the physical condition of the 
infant. All infants, even those that are satisfactorily gaining in weight, 
should be seen and carefully examined from time to time by the physician 



WEIGHT DURING INFANCY AND EARLY CHILDHOOD 15 

in order to determine their true physical condition. The infant should be 
stripped and weighed upon the same scales, by the same person and at the 
same time of day, so that all the conditions may be as nearly alike as pos- 
sible at the different weighings. 

The average birth weight of the normal infant at term is about seven 
pounds; female infants are, on the average, from one-half to one pound 
lighter than males. Great variations in the birth weight may occur ; in full- 
term infants which on inspection appear to be satisfactorily developed a 
birth weight of over six pounds may be considered normal. In proportion 
as the birth weight falls below six pounds the vitality of the infant is im- 
paired and its chances for normal development diminished. The infant 
loses in weight for two or three days following its birth ; the most rapid loss 
occurs during the first day, and by the third or fourth day the child begins 
to slowly gain in weight. This initial loss of weight amounts to from five 
to seven ounces; the lowest weight of the baby is commonly found on the 
third day, and by the end of the first week it regains its birth weight. This 
loss of weight is largely due to the discharge of meconium and urine and the 
absence of food and water. If newly-born infants are given water to drink 
(which may be fed to them with a medicine dropper, two or three tea- 
spoonfuls every three hours), the initial loss of weight here described will 
be diminished, and the water thus given will serve a valuable purpose in 
increasing the urinary secretion and washing out the tubules of the kidney. 

From the end of the first week the normal infant gains rapidly in 
weight, beginning with an ounce a day, or about two pounds every month. 
This rate of increase is maintained up to and perhaps throughout the third 
month of life. Toward the end of the third month and throughout the 
fourth there is a slight falling off in this gain of weight ; during this time 
the increase is gradually diminished to five ounces a week, and the infant 
still continues to gain slightly less in weight, until at the end of the sixth 
month it is gaining only four ounces a week. From this time to the end 
of the year it averages from three to three and one-half ounces a week. 
By this rate of increase an infant weighing seven pounds at birth should 
weigh fourteen pounds at six months and twenty pounds at one year of age. 
This wonderful growth, by which the infant doubles its weight during the 
first six months of life, and almost triples its weight by the end of the 
first year of life, together with the rapid heat loss of this period, is responsi- 
ble for many of the physiological and pathological peculiarities of infancy, 
and explains the large amount of food required per kilogram of weight, the 
intense activity of the metabolic processes, and the great demands made 
upon the excretory organs during this period of life. 

After the first year of life the increase in weight gradually becomes less 
rapid. During the second year the child gains about three-fourths of a 
pound a month, or nine pounds during the year. In the third year of life it 
gains about four and one-half pounds ; during the fourth year its weight is 
increased three pounds, and in the fifth year two and one-half pounds, at 
which time it should weigh from forty to forty-one pounds. From the end 
3 



GROWTH AND DEVELOPMENT 



16 




FlG 2 _ THE IUt. o, Gbow™ » W»h 7 D CLL , M EDl oc BE *n> PB.OOCO.S 
Iig. *• a"^ Boys AND Girls. 

p , hovs . weig ht Dashed lines represent girls' weight. (W. T, Porter.) 
Full lines represent boys weignt. *-> 

tamed for several years. But J«^» ig ohan g ged; the boys 

itself felt, the ^^^^J^f^L above'theirs. This 
iose their supenonty ^and the curve of g* g^ ^ ^ ^ ^ 

difleren nd tCvouth n^reVavier' thau the m aid. In the plate the 
Xs of gWs -i g ht cross the hoys' curves at the sa^e age m dull, 
mediocre and precocious children.' 



HEIGHT OF CHILD AT DIFFERENT AGES 



17 



Height of Child at Different Ages. — The average length of the male 
newly-born infant is twenty inches, the length of the female is about one- 
half inch less. According to Botch, whose figures are in close accord with 
those of other observers, the most rapid growth occurs within the first 
month, during which time the infant is increased in length one and three- 
fourths inches and during the second month one and one-half inches. From 
the third to the twelfth month the rapidity of growth becomes gradually 
less, until at the end of the first year of life the average increase is about 
one-half inch per month. The child gains eight inches in length during the 
first year; three and one-half inches during the second year, and three 
inches during the third year ; thereafter the gain is from two to two and one- 
half inches each year up to the eleventh year of life. As the period of 
puberty approaches there is a more rapid gain in height, which corresponds 
rather closely with the rapid increase in weight which occurs at this period. 
This increased rate of growth begins about the twelfth year in girls and 
about the thirteenth year in boys and continues for two or three years, and 
during this time the increase in height is from three to four inches per 
annum. It is not improbable that the rapid body growth and rapid func- 
tional development of the nervous system, which are frequently associated 
with nervous irritability, mental precocity, tachycardia, headache, and other 
nervous symptoms, may be produced by excessive activity of the thyroid 
gland which occurs with the approach of puberty. At any rate, it is im- 
portant to recognize the fact that during this period of rapid growth and 
development the child is to be carefully protected from excessive brain work 
and nerve excitement. 

The following tables from Koplik give the average height, weight, head 
circumference and chest measurements of American boys and girls. They 
are collated from thousands of children in various states by Bowditch, Burk, 
MacDonald, Hastings and Chapin: 



Table 1 
From Birth to Four Years of Age 



Age 


Sex 


Length 


Weight 


Head 
Circum. 


Chest 
Girth 


Birth 

6 months . . . 
12 months . . . 

2 years 

3 years 

4 years 


/ Boys. 
1 Girls. 
/ Boys. 
j Girls. 
/ Boys. 
\ Girls. 
/ Boys. 
\ Girls. 
/ Boys. 
\ Girls. 
J Boys. 
1 Girls. 




In. 
19.7 
19.3 
25.4 
25.0 
29.5 
28.7 
33.8 
32.9 
37.0 
36.3 
39.3 
38.8 


Cm. 

50.0 
49.0 
64.8 
63.6 
73.8 
73.2 
84.5 
82.8 
92.6 
90.7 
98.2 
97.0 


Lbs. 
7.4 
7.1 
16.0 
15.5 
21.5 
21.0 
30.3 
29.2 
34.9 
33.1 
37.9 
36.3 


Kilos. 
3.45 

"7.2 

7.0 

9.8 

9.5 

13.8 

13.3 

15.9 

15.0 

17.2 

16.5 


In. 
13.8 
13.1 
16.0 
16.4 
17.8 
18.2 
19.3 
18.0 
19.3 
19.0 
19.7 
19.5 


Cm. 
35.1 
33.4 
40.5 
41.7 
45.3 
46.3 
49.0 
45.6 
49.0 
48.4 
50.3 
49.6 


In. 
12.6 
11.8 
15.7 
15.2 
17.8 
19.0 
20.0 
18.0 
20.1 
19.8 
20.7 
20.5 


Cm. 
32.0 
30.0 
39.9 
38.6 
45.1 
48.3 
50.8 
4S.0 
51.1 
50.5 
52.8 
52.2 



18 GROWTH AND DEVELOPMENT 

Table 2 
From Five and a Half to Fifteen and a Half Years 



Years 
of age 


Sex 


Height 


Weight 


Head 
Circum. 


Depth 
of Chest 


Breadth 
of Chest 


Chest 
Expansion 






In. 


Cm. 


Lbs. 


Kilos. 


In. 


Cm. 


In. 


Cm. 


In. 


Cm. 


In. 


Cm. 


5V 2 ... 


/ Boys 


41.7 


105.9 


41.6 


18.9 


20.1 


51.2 


4.9 


12.3 


7.1 


18.1 


1.3 


3.4 


j Girls. . . . 


41.3 


104.9 


40.7 


18.5 


19.7 


50.2 


4.8 


12.3 


7.0 


17.7 


1.4 


3.5 


m... 


f Boys 


43.9 


111.9 


45.2 


20.5 


20.2 


51.5 


5.0 


12.8 


7.2 


18.4 


1.6 


4.2 


j Girls. . . . 


43.3 


109.0 


43.4 


19.5 


19.8 


50.3 


4.9 


12.3 


7.0 


17.7 


1.5 


3.8 


7X... 


/ Boys 


46.0 


116.8 


49.5 


22.5 


20.4 


51.9 


5.1 


12.9 


7.4 


18.9 


1.8 


4.5 


1 Girls. . . . 


45.7 


116.0 


47.7 


21.6 


20.0 


50.9 


4.9 


12.5 


7.2 


18.4 


1.8 


4.5 


sy 2 . 


/ Boys 


48.8 


123.9 


54.5 


24.4 


20.5 


52.2 


5.1 


12.8 


7.6 


19.4 


2.3 


5.9 


\ Girls.... 


47.7 


121.1 


52.5 


23.8 


20.2 


51.2 


4.9 


12.5 


7.4 


18.9 


2.0 


5.0 


9y 2 . 


/ Boys 


50.0 


127.0 


59.6 


27.0 


20.6 


52.4 


5.2 


13.2 


7.8 


19.7 


2.5 


6.5 


j Girls.... 


49.7 


126.2 


57.4 


26.0 


20.4 


51.9 


5.1 


13.1 


7.0 


19.3 


2.2 


5.6 


ioy 2 . 


/ Boys 


51.9 


131.8 


65.4 


29.5 


20.6 


52.6 


5.2 


13.2 


8.0 


20.2 


2.7 


7.0 


\ Girls.... 


51.7 


131.3 


62.9 


28.5 


20.5 


52.0 


5.1 


13.0 


7.8 


19.8 


2.4 


6.0 


uy 2 . 


/ Boys 


53.6 


136.1 


70.7 


32.2 


20.8 


52.9 


5.4 


13.8 


8.2 


20.9 


2.9 


7.3 


j Girls.... 


53.8 


136.6 


69.5 


31.5 


20.7 


52.5 


5.2 


13.1 


8.0 


20.3 


2.6 


6.6 


uy 2 . 


/ Boys 

1 Girls 


55.4 
56.1 


140.7 
142.5 


76.9 

78.7 


34.9 
35.7 


21.0 
20.9 


53.3 
53.0 


5.6 
5.4 


14.1 
13.8 


8.5 
8.4 


21.5 
21.0 


3.0 
2.4 


7.8 
6.2 


isy 2 . 


/ Boys 


57.5 


146.0 


84.7 


38.5 


21.1 


53.5 


5.6 


14.3 


8.7 


22.7 


3.2 


8.2 


1 Girls.... 


58.5 


148.6 


88.7 


40.3 


21.0 


53.5 


5.5 


14.1 


8.7 


22.1 


2.6 


6-6 


uy 2 . 


/ Boys 


60.0 


152.3 


95.2 


43.2 


21.3 


54.1 


5.9 


15.0 


8.9 


22.7 


3.3 


8.4 


j Girls.... 


60.4 


153.4 


98.3 


44.6 


21.3 


54.1 


5.7 


14.5 


9.0 


22.9 


2.7 


6-8 


isy 2 . 


/ Boys 


62.9 


159.7 


107.4 


48.8 


21.4 


54.5 


6.3 


16.0 


9.3 


23.6 


3.3 


8.4 


\ Girls.... 


61.6 


156.4 


106.7 


48.5 


21.5 


54.6 


6.0 


15.3 


9.5 


23.8 


2.6 


6-5 



Head Measurements. — Slight variations from the head measurements in 
the above tables recording the maximum circumference at different ages of 
infancy and childhood may occur without special pathological import, but 
marked variations usually have pathological significance. On the average 
the mentally defective have smaller and less symmetrical heads than normal 
children of like age. When symptoms indicating imbecility in the infant 
exist, a small circumference of the head associated with lack of symmetry 
of the skull would be confirmatory evidence. An unusually large circum- 
ference of the head when associated with other signs of hydrocephalus may 
also point to lack of mental development. It should also be remembered 
that a comparatively large head is a not uncommon symptom of rickets and 
cretinism. 

The anterior fontanels, even in the normal infant, may vary in size 
from one-half inch in both its diameters to a lateral measurement of two 
and one-half inches, and an anteroposterior measurement of three inches. 
This opening may not materially decrease in size until the eighth or ninth 
month, when it gradually begins to grow smaller. At the end of the year 
it should not be more than one and one-half inches in diameter and should 
be closed by the eighteenth or twentieth month. Variations as to the time of 
closure of this fontanel may occur, within the limits of good health, from 
the end of the first to the end of the second year of life. Its failure to close 
by the end of the second year of life is commonly an indication of rickets, 
of malnutrition, or of some more serious disease such as hydrocephalus or 
imbecility. The posterior fontanel commonly closes within the first six 
weeks, but in deciding upon the pathological import of open fontanels, after 
their normal period of closure, other symptoms must be taken into con- 






DEVELOPMENT OF SPINE AND BONY FKAMEWOBK 19 

sideration. In microcephalic skulls the fontanels may close and premature 
ossification of the sutures may occur early. This condition is associated 
with a small, asymmetrical head and lack of development of the brain. 
Both hydrocephalus and microcephalus are elsewhere described. The soft- 
ness of the skull bones and the open fontanels of the young infant pre- 
dispose it to pressure deformities. At this age permanent deformities or 
irregularities in the shape of the skull may be produced by permitting the 
infant to habitually rest its head in one position. 

Development of the Spine and Bony Framework. —The spine of the in- 
fant at birth, as Eotch has noted, contains so much cartilage and so little 
bone, and is so feebly supported by weak and undeveloped ligaments and 
muscles, that it can be easily bent, twisted, and deformed. Instead of the 
normal curves of the self-sustaining spinal column of late childhood and 
adult life, there are present the position curves which result from bending 
and twisting the soft flexible spine of the infant under the influence of 
weight and pressure. The young infant should spend nearly all of its time 
in a prone position. It should, however, be shifted from side to side, or 
back to stomach, so that habitually lying in one position may not pre- 
dispose to permanent pressure deformity of the head or the spine. As the 
infant grows older, the spine becomes stronger and more capable of assisting 
in the support of the body of the infant, but it is important that during the 
latter half of the first year of life the infant be not encouraged to sit up too 
frequently or too long at a time. Throughout early childhood there is a 
gradual development in the bones and supporting ligaments and muscles of 
the spine, but long after school life has begun the spinal column still re- 
mains so flexible that permanent deformities may result from wrong posi- 
tions in writing or other work over low school desks, which cause the child 
to sit for hours each day with a bent or twisted spine. This is a common 
cause of spinal curvatures in school children, many of which are so pro- 
nounced that the most skilful orthopedic treatment over a period of years 
fails to remove the deformity entirely. 

The whole bony framework of the child is in an active stage of growth 
and functional development, but from a pathological standpoint the most 
important processes are taking place in the epiphyses of the long bones, and 
in the small bones which enter into the formation of the ankle and wrist. 
This rapid metabolism and growth of new bone predispose this part of the 
bony framework to tuberculous, pyogenic and other infections. 

Pryor used the development of the bony framework of the wrist as an 
anatomical index to the general development of the skeleton, and his tables 
show that the bony development is more advanced in girls than it is in 
boys of the same age. Eotch in a very clever and far-reaching research has 
demonstrated that Eontgenographs of the carpal bones and epiphyses of 
the radius and ulna may be used to indicate the actual bony and muscular 
development of the child. In this way may be determined the anatomic 
age, which does not always correspond to the chronologic age of the child. 
The anatomic age, as determined by the degree of development of the 



20 



GROWTH AND DEVELOPMENT 



carpal bones and epiphyses of the radius and ulna, determines the degree 
of development of the whole bony and muscular framework of the child, 
and is a fairly accurate index of its capacity for mental and physical work. 
Rotch says, "The people must be educated up to the plane of intelligently 
seeing that, because an individual has been born three or four years, this 
does not necessarily mean that such chronologic age should be rigidly 
adopted for entering a kindergarten; that, because it is six or eight years 

of chronologic age, it should 
necessarily be in the usual 
grade in school corresponding 
to that age; that, because it is 
ten or twelve chronologic years 
of age, it should necessarily be 
grouped in athletics with boys 
or girls of that chronologic 
age; or, because it is fourteen, 
fifteen or sixteen years of age, 
it should be allowed to work 
beyond what its anatomic de- 
velopment shows it can do 
without physical harm, as, for 
instance, in the mills." 

Rotch has worked out a 
practical system of grading 
children for school and other 
work which will correct, he be- 
lieves, the errors which result 
from the classification of chil- 
dren for this work by their 
chronologic age, or by their ap- 
parent physical development as 
determined by weight and 
height. The value, however, of 
the weight and general appear- 
ance of the child as a simple 
and practical method of classi- 
fying him for his school work has been already referred to and must for a 
time at least remain the simplest and most practical method of classification. 
The more scientific and more accurate method of determining the anatomic 
age of the child by Rontgenization may, as Rotch believes, in time super- 
sede the cruder and simpler methods. 

Muscular Development. — The general bony framework of the body keeps 
pace with the muscular development of the child and attains sufficient 
stability to support the positions of the body which the child instinctively 
assumes in the physiological activity of its developing muscles. It is in- 
advisable, however, and may be positively injurious to place the child in 







Fig. 3a. — Bad Position While Whiting. 
(After Hoffa in Pfaundler and Schlossmann.) 



MUSCULAE DEVELOPMENT 



21 



sitting or standing positions before its muscular development is such that 
it voluntarily or instinctively attempts to assume these positions. The young 
infant as it lies upon its back should have perfect freedom of muscular 
movement, and as its muscular development grows apace it instinctively 
attempts to change its position. It does not have to be taught to turn over 
in bed, to lift its head from the pillow, to attempt to crawl or to make an 
effort at sitting up or climbing upon its feet; all of these movements are 
instinctive in the normal child, 
and they are exercised as soon 
as its muscular development is 
equal to the physical effort 
which these movements entail, 
and as soon as the bony frame- 
work of the body is able to as- 
sist, without injury, in sup- 
porting the infant in these po- 
sitions. At birth the muscular 
development of the hands and 
forearms is relatively stronger 
than the rest of the body. The 
young infant clings to objects 
that are placed in its hand, 
and in the latter part of the 
third or beginning of the 
fourth month it reaches for 
and takes hold of objects which 
are placed in front of it. At 
birth the infant is unable to 
hold its head in an upright 
position, but during the third 
or fourth month the muscles 
of the neck have sufficiently 
developed for the child to lift 
its head from the pillow and 
hold it in an upright position 
for a short time. From this 

time on the infant begins to assume positions in which the whole spinal 
column is held in a mild degree of temporary rigidity. By the eighth or 
ninth month it may be able to sit alone for a short time, and about this 
time it begins to crawl and attains in a mild degree the faculty of volun- 
tary locomotion. About the ninth or tenth month its first attempts at pull- 
ing itself upon its feet are made, and thereafter it soon acquires the power 
to stand and to make an effort at walking, when it is supported by a chair or 
some other object. When eleven or twelve months of age it may, while 
clinging to some object, begin to walk, but is not, as a rule, able to walk 
alone until it is fifteen or sixteen months of age. It should be remembered, 




Fig. 3&. — Bad Position While Writing. 
(After Hoffa in Pfaundler and Schlossmann.) 



22 GROWTH AND DEVELOPMENT 

however, that even in normal infants there is considerable variation as to the 
time when they begin to make various movements. Some may walk alone 
when ten or eleven months of age, and others without apparent evidence of 
disease may not attain this faculty until they are eighteen months of age. 
The late development, however, of the physical functions here outlined is, 
especially when associated with other symptoms, important evidence of dis- 
ease or lack of development on the part of the nervous system. Inability 
to hold the head upright at the fifth month, failure to reach for and grasp 
objects in the fifth or sixth month of life, failure to maintain a sitting 
position at one year of age, no inclination to assume the upright position 
at the eighteenth month and failure to walk when two and one-half years 
of age are indications not only of lack of muscular and bony development 
but of nervous development as well. In such instances a careful search 
should be made for other signs of disease or lack of development of the 
nervous system. 

Special Senses. — The infant during the first few days of life is deaf 
and this condition perhaps continues until the Eustachian tubes are cleared 
of mucus, and air has found its way into the internal ear. During the first 
three or four days the infant, for this reason, sleeps soundly, undisturbed by 
surrounding noises. From the third to the fifth day there are indications 
that the child hears and thereafter this sense gradually becomes more acute 
until by the end of the first month of life the child is disturbed by slight 
noises, and by the end of the fifth or sixth month it is able to distinguish 
between and interpret certain noises such as the sound of individual voices. 
After this time infants are very sensitive to and easily frightened by loud 
and unaccustomed noises. 

Soon after birth the eyes are sensitive to light and for this reason during 
the first weeks of life they should not be exposed to bright lights. At 
the end of the second or third week the eyes of the infant will follow 
a bright light as it is moved in front of its face. From this time on it 
notices more and more bright moving objects, and at the end of the third 
month it not only sees all objects within its range of vision, but it may 
give evidence that it recognizes its nursing bottle or some other object 
which it has seen before. 

The sense of taste is perhaps slightly developed at birth, as an infant 
a few days old takes sweetened food more readily than it will sour or bitter 
liquids. This inborn preference for sweet food is not to be unduly en- 
couraged, as even very early in the life of the infant it may lead, in 
artificially fed infants, to the giving of an excess of sugar simply because 
the infant demands it. 

The function of speech is developed earlier in girls than it is in boys. 
At the twelfth or thirteenth month the infant may say mama and papa, 
toward the close of the second year simple short sentences may be used, 
and thereafter the faculty of speech is more rapidly developed. It is not a 
very unusual thing in children of normal intellectual development to have 
the speech faculty delayed for a year or more after the time when it is 



NERVOUS SYSTEM 23 

usually acquired by the normal child. These children all through the 
latter half of the first year of life and through the second year manifest 
the same signs of intelligence as the normal child; they understand every- 
thing that is said to them and make their wants known by signs and by 
articulate sounds which by long use have become intelligible to those around 
them. 

Nervous System. — The dura mater in the infant is closely adherent to 
the skull, and the blood vessels of the pia mater are so abundant and so 
fragile that hemorrhage into the subarachnoid space may result from causes 
which produce high blood pressure. This accounts for the not infrequent 
occurrence of cortical hemorrhage during labor and also explains why 
paroxysms of whooping cough and severe convulsions may produce this ac- 
cident in older children. The serious effect on the mental and physical 
development of the child which results from these hemorrhages is not so 
much due to their extent as it is to the fact that they produce a permanent 
cortical lesion in the young and immature brain which interferes with its 
structural and functional development. 

Of all the vital organs the nervous system at birth is both structurally 
and functionally the most immature. Throughout infancy and childhood 
the nervous system develops very rapidly in size and structure and much 
less rapidly in function. In the later years of childhood the functional de- 
velopment of the entire nervous system is much more rapid. From birth 
up to the seventh year of life the brain develops enormously in weight, 
in structure, and much less rapidly in function. At this time it has at- 
tained 90 per cent, of its maximum weight (Boyd), and thereafter it slowly 
increases until it has attained its maximum size at the age of eighteen ; but 
increase of function does not keep pace with increase of weight. While 
the brain of the child at eight is almost as large as that of the adult, as 
Clouston says, "The difference between what the brain of a child of eight 
and the brain of a man of twenty-five can do and can resist is quite in- 
describable. The organ at these two periods might belong to two different 
species of animals so far as its essential qualities go." The important 
structural changes in the brain of the child pertain to the development of 
the convolutions and their arrangement in groups which preside over spe- 
cial functions, but it should be remembered that even in the normal child 
irregularities may occur in the order of development of both structure and 
function. It is quite within the limits of health that certain functions of 
the nervous system may be rapidly developed and that others may be 
unusually retarded. While this is true, the important pathological fact 
must be kept in mind, that many factors such as heredity, nutritional con- 
ditions and environment have a very powerful influence on both the struc- 
tural and functional development of the nervous system, and these factors, 
if unfavorable, seriously retard the growth of the nervous system in both 
structure and function and very commonly interfere with the order of 
development of important functions. 

The most important clinical fact to be derived from these observations 



24 GEOWTH AND DEVELOPMENT 

is that the nervous system of the infant and young child, by reason of its 
rapid growth and immaturity, is characterized by marked nervous irrita- 
bility and extreme excitability, and that this normal irritability and ex- 
citability of nerve cells and nerve centers in the young nervous system may 
be greatly exaggerated by malnutrition, bad heredity and unfavorable en- 
vironment. The above facts in part explain the peculiar susceptibility of 
the child to functional nervous diseases and also explain the powerful in- 
fluence of bad heredity, malnutrition and unfavorable environment in de- 
veloping and aggravating these disorders at this period of life. 

Feeble inhibition is one of the most important peculiarities of the 
nervous system of the child. The inhibitory mechanisms which control the 
discharge of nerve force that regulates such vital processes as the action 
of the heart and lungs are fairly well developed at birth, while those that 
regulate reflex phenomena are very immature, and are slowly developed 
throughout infancy and early childhood. The late development of the func- 
tion of inhibition is a fact of great importance from a clinical standpoint, 
because this is the last function of the cell to be developed, and is therefore 
the one that is most likely to be still further retarded in development by 
bad heredity, malnutrition and unfavorable environment. It is the ab- 
normally feeble inhibition which occurs in the abnormal child, brought 
about by the above-named unfavorable conditions, that is such a powerful 
factor in the production of neurotic disease in infancy and childhood. 

One can readily understand how feeble inhibition even in the normal 
child, by reason of an insufficient control over the convulsive centers at the 
base of the brain and reflex centers in the spinal cord, may predispose to 
convulsive and other neurotic disorders of childhood, and one can also 
readily see how bad heredity, malnutrition and unfavorable environment, by 
retarding the normal development of the inhibitory function of the nervous 
system, may be all-important factors in the development of these neuroses. 

Certain of the reflex centers in the spinal cord which preside over 
special functions, such as urination and defecation, are so functionally im- 
mature at birth that there is a lack of tone of the sphincter muscles over 
which they preside, and as a result we have an incontinence of feces and of 
urine. These reflex centers are slowly developed until, under their control, 
the muscles of the bladder and rectum acquire the normal muscular tone 
which fits them for the purposes they are to serve, and with this development 
the centers in the cord assume control of the rectum at about the fifth 
month and complete control of the bladder muscles at about the end of the 
second year of life. 

It is a fact of great physiological and pathological importance that in 
the development of the spinal cord the fibers of the pyramidal tract are 
the latest to become myelinated. At birth they have almost no myelin 
sheaths and until these are developed it is believed that motor impulses 
cannot readily be carried from the brain to the spinal cord cells. 1 "Day by 

1 For a fuller discussion of the physiological peculiarities of the nervous system 
during infancy and childhood, see the author's monograph " Neurotic Disorders of 



DEVELOPMENT OF HEAT-REGULATING MECHANISM 25 

day as these myelin sheaths are developed the cerebral and spinal motor 
cells are brought into closer communication so that at about the third or 
fourth month this communication may be said to be fairly well established ; 
prior to this time the communications are imperfect." These physiological 
facts may be offered in explanation of the comparative immunity which 
young infants have from convulsive disorders during the first few months 
of their lives, and they may also explain the development of spastic palsies 
as late as the third or fourth month of life which are due to natal and pre- 
natal injuries to the brain. 

Development of the Heat-regulating Mechanism. — The rectal tempera- 
ture of the normal newly-born infant at term ranges between 99.5° and 
100.5° F., and this temperature is maintained with little variation through- 
out the first nine months of life. During the second year of life the 
normal temperature varies from 99° to 100° F., and thereafter through- 
out early childhood the rectal temperature is from 99.6° to 100.5° F. 
Throughout infancy and early childhood variations in temperature between 
98.5° and 100° F. are of little or no pathological significance. Under the 
heading, Management of Premature Infants, the fact is noted that in 
congenitally weak infants the temperature ranges much lower than the 
figures here given. It is a notable fact that slight causes acting upon the 
unstable heat-regulating mechanism of the infant and young child will 
produce high and variable temperatures, while the same causes acting upon 
the mature nerve centers of the adult may produce no variations in the 
temperature curve. 

The thermogenic or heat-producing centers are located at the base of 
the brain. These centers have the function of discharging force which will 
increase tissue metabolism and thereby increase the body heat. Any disease 
or injury which destroys the efficiency of these centers would cause a de- 
crease of the body heat, and any condition which increases the irritation of 
or unduly excites these centers would increase the body heat. Before birth 
the thermogenic centers are in a state of immature functioual development. 
In the human infant born prematurely they are so imperfect that artificial 
heat is necessary to keep the body warm, and this artificial heat must con- 
tinue to be supplied until these immature centers have developed to such a 
state of physiological competency that they are able to supply to the body 
the normal amount of heat. In the normal infant at birth, although these 
centers have a fair degree of physiological competency, they are still im- 
mature, and much more unstable than they are in the finished brain of 
the adult. The comparative instability and excitability of the thermogenic 
centers of the infant and young child cause them to discharge their nerve 
force and increase the body temperature from slight causes, and in this fact 
we find one of the explanations of the proneness of infants and young chil- 
dren to develop high temperatures from slight causes. 

Like other nerve centers in the unfinished brain of the child the thermo- 

Childhood, '■' 1905, and "Clinical Significance of Lack of Development of the Pyra- 
midal Tracts in Early Infancy," Archives of Pediatrics, 1910. 



26 GROWTH AND DEVELOPMENT 

genie heat centers have their normal irritability and excitability very greatly 
exaggerated by neurotic inheritance, malnutrition and unfavorable environ- 
ment. It is the abnormal excitability of these centers in the nervous, mal- 
nourished, anemic child that explains the special predisposition which some 
children have to fever from slight causes. 

The thermoinhibitory centers are located in the cerebral cortex and it is 
their function to control or prevent the discharge of nerve force from the 
thermogenic centers. The thermogenic and thermoinhibitory centers have 
their functions so nicely balanced in the normal adult nervous mechanism 
that with the aid of the heat-dissipating centers they are able to maintain 
the body at almost a uniform temperature under the most adverse circum- 
stances. But in the infant and young child the thermogenic centers are 
not only irritable and excitable, but they are under comparatively feeble 
inhibitory control from the thermoinhibitory centers, and this feeble inhibi- 
tion of the thermogenic centers, which predisposes the normal child to high 
and variable temperatures from slight causes, is much more feeble and 
therefore much less effective in children of bad heredity, malnutrition, and 
unfavorable environment. It is therefore the abnormally feeble inhibition 
of the nervous, malnourished, anemic child which leads to loss of control 
of the thermogenic centers, that especially predisposes certain children to 
high and variable temperatures. McAllister says, "The inhibitory is the 
first portion of the heat-regulating mechanism to fail under injury or 
disease." 

The heat-dissipating mechanism plays a much more important part in 
regulating the temperature of the body in the infant and child than it does 
in the adult. This is the mechanism by which the infant keeps itself cool 
when from insufficiency or maladjustment of the thermogenic and thermo- 
inhibitory centers the temperature of the child is raised above the normal 
point. The dissipation of heat by radiation and conduction and by the 
constant evaporation of water from the surface of the body is much more 
rapid in the infant, because the area of skin surface is from four to six 
times greater in the infant and young child in proportion to its body 
weight than it is in the adult. For these reasons the heat-dissipating 
mechanism of the infant is four times as effective as it is in the adult. In 
the above physiological facts we have an explanation of why the high 
temperatures of infancy and childhood are so readily reduced by the heat- 
dissipating mechanism, and we also have an explanation of the compara- 
tively rapid reduction of temperatures at this time of life from hydro- 
therapeutic measures and from medical antipyretics. These latter act not 
only on the thermogenic centers in diminishing the amount of heat pro- 
duced, but they also act through the vasomotor nervous mechanism and 
cause a profuse perspiration with a resulting rapid evaporation of the 
water from the surface of the body. It will thus be seen that the heat- 
dissipating mechanism in infancy and childhood is much more effective than 
it is in later life, and that in the play of function between this mechanism 
and that of the heat-generating and heat-inhibiting mechanism we have an 



EVAPORATION OF WATER FROM AIR PASSAGES 27 

explanation, not only for the high temperatures which occur during infancy 
and childhood from slight causes, but also for the unusual variations in the 
temperature which occur at this period of life. As the infant develops into 
the child and as the child grows older there is a gradual functional develop- 
ment of the heat-regulating apparatus. The thermogenic centers become 
less irritable and are therefore not so easily excited to produce fever from 
slight causes. The thermoinhibitory centers gradually increase their effi- 
ciency and exercise more and more control over the thermogenic centers; 
this is especially important in increasing the stability of these heat centers, 
and of preventing fever from slight causes. With this increase in stability 
and functional capacity of the heat centers, the heat-dissipating mechanism 
also becomes more stable and does not respond so readily to hydrotherapeutic 
and other measures commonly used for the reduction of temperature. 

Evaporation of Water from the Air Passages. 1 — In certain animals, the 
dog for instance, which do not sweat, the evaporation of water from the 
air passages is the chief means of reducing the body temperature. Richet 
calls the rapid respirations of the panting dog polypnea; by these rapid 
respirations, amounting to as many as four hundred in a minute, the heat 
of the body is rapidly given off. Ricbet proved that the polypneic center 
was not affected by the amount of carbonic acid or oxygen in the blood, 
and that it was solely for the purpose of heat dissipation. 

Does the polypneic center exist and is it functionally active in infancy 
and childhood? The answer to this question has important clinical bear- 
ings. Ott says: "In infants we see a polypnea during fever, the respira- 
tion rises in frequency with the rise in temperature." Every physician must 
have seen many cases of rapid respiration in children that could not be 
accounted for by pulmonary disease. It not infrequently happens that a 
child with fever will have sixty, eighty and one hundred respirations per 
minute, without presenting any sign or symptom of lung trouble. Polyp- 
nea is, to my mind, the explanation of this phenomenon. Very rapid 
breathing is a common symptom of gastrointestinal disorders, and in many 
cases means nothing more than nature's attempts at heat dissipation. The 
importance of recognizing polypnea as a symptom of fever in infancy and 
childhood is great. If we do not do this, we may often be led, by the rapid 
breathing, away from the real cause of the disease. Fortunately for us as 
clinicians, there is a marked difference between the character of the 
polypneic breathing and the rapid respirations due to lung or heart dis- 
ease. In polypnea the breathing is regular, easy and rapid, but is not, 
as it is in lung and heart disease, irregular, labored and accompanied by 
cyanosis. 

1 "Neurotic Disorders of Childhood," by B. K. Eachford, E. B. Treat & Co., 
N. Y., 1905. 



28 EXAMINATION OF THE SICK CHILD 

CHAPTEE III 
EXAMINATION OF THE SICK CHILD 

HISTORY OF THE CASE 

Present Illness. — The first step in the routine examination of the sick 
child is to listen attentively to the mother's and nurse's story of the child's 
present illness. In this short narrative the physician should obtain clues 
which will materially assist him in his own careful physical examination 
of the child. It is all very well for us to say that a full and complete ex- 
amination should be made of every sick child, but this is manifestly impos- 
sible and in a sense unnecessary. It would be unwise and unnecessary, even 
if the physician had the time, to thoroughly examine in every case presented 
to him the blood, the sputum, the stools, the cerebrospinal fluid and the 
gastric contents, or to test the child's special senses and make a thorough 
examination of all of its reflexes. These and many other special examina- 
tions may be suggested by the story of the child's illness or by the subse- 
quent careful physical examination to which the child is subjected. The 
diagnostic skill of the physician will largely depend on his ability to de- 
termine from the mother's story what should be the character of his pre- 
liminary examination and to judge from the findings of this examination, 
or the subsequent developments of the case, what special examinations may 
be necessary to clear the diagnosis in an individual case. 

Previous Medical History. — Obtain the medical history of the child as 
to previous illnesses and especially as to similar attacks; the character of 
food it has been taking ; the regularity of its habits in eating and sleeping ; 
gastrointestinal disorders; acute infectious diseases; nervous disturbances 
and possible birth and subsequent injuries. Special inquiry along certain 
lines suggested by the story of the present illness may bring forth facts of 
great importance in the child's previous history which the mother would 
otherwise have overlooked. 

Family History. — With the story of the child's previous and present 
illness in mind, the physician is better prepared to obtain from the mother 
such facts in the family history as may have a bearing upon the case. It 
is especially important to know the number of other living children and 
their general health ; the number of the dead and the causes of their death. 
It may be necessary in an individual case to inquire carefully into the 
family history with reference to syphilis, tuberculosis, nervous disorders, 
gout, autotoxic attacks, gastrointestinal disturbances, a hemorrhagic diathe- 
sis, or other conditions in the ancestry of the child, which may throw light 
upon its present illness. 



PHYSICAL EXAMINATION 29 



PHYSICAL EXAMINATION 

If the child is approached gently and tactfully it is possible to make this 
examination without resistance from the little patient. In order that the 
various steps of the physical examination may be made under the most 
favorable conditions it is wise to postpone the taking of temperature and 
the examination of the throat until the last, as these procedures may irri- 
tate the child. 

The rectal temperature should be taken at the first examination and 
thereafter should be recorded at least twice a day until a diagnosis is 
reached. In many instances it is necessary to take the temperature at three- 
hour intervals, and, as a rule, it is advisable that a careful temperature 
record be kept until the child is convalescent. The value and significance 
of temperature observations have been outlined in the chapter on Fever. 

The weight of the child should be ascertained, if possible, at the first 
examination. This observation helps the physician in determining the 
child's general physical condition and when compared with future weigh- 
ings enables him to determine whether the child is losing or gaining 
weight. The importance of failure to gain in weight, as an indication of 
disease in the growing child, has been referred to in the chapter on Growth 
and Development. 

Inspection. — More information may be obtained by inspection than by 
any other method of physical examination. That this may be thorough, 
the whole body of the child should be examined. The experienced eye can 
almost at a glance read the nutritional history of the child in the general 
picture which its nude form presents. It is important to note muscular 
development, general emaciation, the size and shape of the head, thorax and 
abdomen, skin eruptions, deformities, localized inflammations, and the 
presence or absence of the external signs of rickets, hereditary syphilis, 
gastrointestinal diseases, and anemia. 

Face and Head. — The facial expression may tell of the presence of 
adenoids, paralysis, and cretinism and other forms of idiocy. The sunken 
eyes, pinched features and dull stare of the child indicate the extreme 
gravity of the illness. The small wasted face, large head and open 
fontanels tell the story of long illness from some chronic wasting disease. 
The rachitic head, the microcephalic head and the hydrocephalic head are 
readily recognized. Opisthotonos, stiffness of the spine and a position 
which shields the eyes from light suggest meningeal inflammation. If the 
head falls loosely in the direction gravity directs, and the spine shows by 
its abnormal flexibility a lack of muscular development, it may be in- 
ferred there is also a lack of mental development. Inspection of the throat 
and mouth commonly throws light on the character of the child's illness. 
One should observe the character of the tongue ; local diseases of the tonsils, 
pharynx, and mucous membranes ; the membrane of diphtheria ; the scarla- 
tinal sore throat, the enanthems of measles and of the other acute exanthe- 



30 EXAMINATION OF THE SICK CHILD 

mata; abnormalities as to the formation of the teeth and the order of 
their eruption ; hemorrhagic and other diseased conditions of the gums, and 
deformities in the shape and general contour of the palate. The skin 
should be carefully examined and one should note the presence and char- 
acter of all rashes; desquamation of the skin and its character; cyanosis 
and its possible relation to dangerous cardiac and respiratory diseases; 
petechial and other hemorrhagic eruptions; jaundice as shown by the yel- 
lowish discoloration of the skin and conjunctiva; edemas, both general 
and localized, the former pointing to nephritis, the latter to urticaria and 
gastrointestinal disorders; marked pallor of the conjunctiva and skin, with 
or without edema, which may give a clue to grave blood lesions; syphilitic 
lesions about the anus; irritations, catarrhal inflammations and other ab- 
normalities of the genitalia, and clubbing and blueness of the finger tips 
which may point to some grave lesion of the circulatory or respiratory 
apparatus. 

The general position of the child lying, sitting or standing gives 
much information. In pleurisy and pneumonia it may lie upon the affected 
side, holding its chest wall and evincing characteristic pain by its facial 
expression and by crying out when it is moved. In abdominal pain it 
usually lies upon its back with its thighs flexed upon its abdomen; this 
position is common in appendicitis, peritonitis, typhoid fever with abdom- 
inal distention, and in severe attacks of intestinal colic. In the standing 
position curvatures of the spine, bow-legs and other body deformities are 
readily detected. 

Eespiratory movements should be carefully observed while the child 
is at rest. Marked dyspnea, with retraction of the chest, and dilatation of 
the alae nasi may not only point to bronchopneumonia, but may indicate 
the seriousness of this disease, or the same symptom group slightly modified 
may be caused by an obstructive lesion in the larynx, such as may occur 
in diphtheria and catarrhal laryngitis. In very young infants difficult and 
interrupted breathing may result from nasal obstruction caused by syphilis, 
acute rhinitis, or retropharyngeal abscess. Slow and irregular respiratory 
movements may be due to intracranial disease. 

Palpation or Digital Examination. — The head and neck are fruitful 
fields for this form of examination. One should note the shape of the 
head, size of the fontanels, thinness of the cranial bones, hypertrophied 
tonsils, enlargement of cervical lymphatics, and swelling of the parotid 
and other salivary glands. A digital exploration may reveal adenoid dis- 
ease or other abnormalities in the pharynx. 

Palpation of the chest may reveal the rickety rosary, or other bony 
deformities, the fremitus produced by the voice and by bronchial and 
sibilant rales, inequalities in the movements of the two sides of the chest, 
the location of the apex beat of the heart, and the cardiac thrill when 
present. By palpation one also determines the rate and character of the 
pulse and general and local enlargement of superficial lymphatic glands. 

In the abdomen one may discover by palpation localized or general 



PHYSICAL EXAMINATION 31 

tonicity and resistance of the abdominal wall, so important in the diagnosis 
of appendicitis, peritonitis and other abdominal diseases; fluid in the ab- 
dominal cavity; enlargement of the spleen and liver; displacement and 
enlargement of the kidneys; tumors and other abnormalities. The liver 
normally extends one inch below the margin of the ribs when the child is 
lying upon its back; it is therefore readily palpable, and enlargements are 
easily detected. The spleen when easily palpable is enlarged and is a diag- 
nostic sign of great importance in typhoid fever, leukemia, von Jaksch's 
disease, chronic forms of tuberculosis and malaria. Enlargement of the 
spleen may also occur in the acute infections, chronic gastrointestinal dis- 
eases and chronic forms of sepsis. 

In the upper and lower extremities one may discover tenderness and 
rigidity of the joints, deformities and lack of symmetry in development. 

The method of examination for determining the rigidity of the spinal 
column is important. Curvatures of the spine are readily discovered when 
the child is undressed, but the character of these curvatures can only be 
made out by careful palpation. The organic curvature due to Pott's disease, 
which is permanent and rigid, is to be differentiated from curvatures due 
to false position and muscular weakness, such as are associated with rickets 
and other malnutritions. The nonflexibility of the spinal curvature of 
Pott's disease as compared with the flexible curvatures from other causes 
is one of the important diagnostic points. In making this examination the 
patient is placed upon the table face downward, the fingers of one hand 
are now gently inserted between the spinal processes over the curvature; 
with the other hand grasping and lifting the ankles of the child, its body is 
bent backward, and as the spine bends with the body the finger inserted 
between the spinal processes discovers no approximation of these processes, 
or, in other words, the spinal curvature remains rigid. In other forms of 
curvature the spinal processes are felt to close upon the fingers as that 
portion of the spine bends under the backward movement. Eetraction of 
the head and opisthotonos, such as one sees in meningitis and certain other 
nervous disorders, may be discovered early by placing the hand under the 
head and lifting the body of the child while the neck remains rigid or bent 
backward. In marked cases the child may be lifted without bending the 
body by placing one hand under the head and the other under the legs. 

Reflexes. — The patellar reflex is one of the most easily developed 
and one of the most important of the deep reflexes. It may be elicited by 
placing the child in a sitting position with its leg flexed at the knee and 
hanging loosely from a chair, or in the infant the leg may be lifted by the 
hand as the infant lies in bed, so that the knee is sharply bent and the 
lower leg hangs loosely over the hand. With the child in one or the other 
of these positions the tendon just below the patella is struck sharply with 
the edge of the hand ; in response to this the muscle contracts and the foot 
is thrown quickly upward. In certain diseases of the nervous system this 
reflex is absent, in others it is exaggerated. An exaggerated patellar reflex, 
especially if unilateral, is of great value in the late diagnosis of spastic 
4 . 



32 



EXAMINATION OF THE SICK CHILD 



palsies due to cortical cerebral hemorrhage in early infancy, and the pres- 
ence or absence of this reflex is of value in locating the site of a transverse 
myelitis. Its absence on both sides locates the myelitis at or below the sec- 
ond lumbar vertebrae. Its presence locates the myelitis above this point. 
The diagnosis of the myelitis itself must, of course, depend upon the other 
symptoms of this disease. 

Babinsky/s Keflex. — This reflex is present in some forms of menin- 
gitis and in all conditions which interfere with the conducting power of 
the pyramidal tracts. It is produced by drawing the tip of the finger across 
the plantar surface of the foot. It consists in a marked hyperextension of 
the great toe with a separation and perhaps extension of the other toes. 
This sign is of no value in children under two years of age, since at this 




Fig. 4. — Palpating Spinal Curvature. 



time of life, by reason of the lack of development of the pyramidal tracts, 
hyperextension of the great toe from plantar irritation is the normal re- 
sponse. Koplik has observed the Babinsky reflex more commonly in tuber- 
culous than in other forms of meningitis, and Morse called special atten- 
tion to the unreliability of this sign in young children. 

Kernig's Sign. — The muscular resistance at the knee joint, which 
makes it impossible to extend the leg when the thigh is flexed at right 
angles to the body, is a sign of meningeal irritation. It is commonly found 
in all forms of meningitis and is sometimes present in meningeal irritation 
from acute toxic conditions such as pneumonia and typhoid fever. 

Percussion. ■ — As Hamill has emphasized, satisfactory results can be ob- 
tained by percussion only when the greatest care is taken to see that all the 
conditions are favorable. In order to distinguish the shades of sound 
elicited, quiet surroundings are absolutely necessary. To develop reliable 
percussion sounds the child should be in proper position. To percuss the 



PHYSICAL EXAMINATION 



33 



front of the chest the child should lie on its back on a firm bed or table; 
the two sides of its body should be symmetrically placed with the face di- 
rected upward and the spinal column straight. For percussing the back it 
should sit on the edge of a table or be held against the chest of the nurse 
with its face over her shoulder, great care being taken to have the spine 
and head straight and the body of the child as relaxed as possible. The 
distal phalanx of the middle finger of one hand is to be used as a pleximeter 
and placed firmly against the chest wall, with the middle finger of the other 
hand the distal phalanx thus placed is tapped quickly but gently. Great 
stress should be laid on very light percussion. The physician by experience 
will learn the force of 
the stroke that serves 
him to the best purpose. 
The value of the percus- 
sion note elicited at any 
point is judged largely 
by comparison with other 
percussion notes elicited 
in other portions of the 
chest. Hamill justly lays 
great stress upon these 
details. He also says 
the percussion of the 
chest of the normal in- 
fant or young child 
yields the following re- 
sults : "On the right, 
from the clavicle to the 
fourth rib, one elicits 
the full normal pul- 
monary resonance. Be- 
low this point, owing to 
the decreased volume of 
lung, and the presence 
behind it of the liver, 

the sound becomes gradually dull and finally passes into the dull sound of 
the liver at the sixth rib. On the left side there is a relatively dull area be- 
hind and beneath the inner third of the clavicle, which sometimes extends 
outward to the mid-clavicular line, and always downward until it fades into 
the cardiac dullness." If percussion is skilfully done much information 
can be obtained concerning the pathological processes going on in the chest 
cavity. It is especially valuable in the diagnosis and differential diagnosis 
of diseases of the lungs, pleura and heart. By it also much information 
can be obtained concerning diseased processes going on in the abdominal 
cavity. Enlargement of the liver and spleen, and fluids, and tumors in the 
abdominal cavity may be mapped out by percussion. 




Fig. 5. — Percussion and Auscultation Position. 



34 EXAMINATION OF THE SICK CHILD 

Auscultation. — The average practitioner obtains much more informa- 
tion by auscultation than he does by percussion. This is partly due to the 
fact that much less experience and skill is required to obtain information by 
auscultation. The position of the infant and child should be the same as 
that above described for percussion, as the auscultatory sounds may be 
readily changed by position. A binaural stethoscope with a small bell 
should be used, so that every portion of the chest wall including the axilla 
may be readily reached. In the auscultation of heart sounds the point of 
greatest intensity should be sought for. This is commonly at the apex or 
the base. The direction in which these cardiac murmurs are carried should 
then be carefully traced. Eespiratory sounds on one side should be com- 
pared with the respiratory sounds at the same point over the opposite lung. 
In interpreting respiratory sounds it is important to remember that the 
expiratory murmur is more intense on the right side beneath the clavicle 
and over the spine of the scapula than it is on the left. The more intense 
respiratory murmur to the right of the sternum and beneath the clavicle is 
in contrast with the area of relative dullness in a somewhat similar posi- 
tion on the left side. It is important also to remember the rough inspira- 
tory sound normally found over the lungs of infants and young children. 
This so-called puerile breathing, if slightly exaggerated, may be mistaken 
for bronchial breathing unless one remembers that the normally rough 
breathing of the infant is especially marked on inspiration, and the patho- 
logical bronchial breathing is more marked on expiration. If the physician 
knows the normal heart and lung sounds, auscultation, if carefully done, is 
of the very greatest value in the diagnosis of heart and lung diseases. 

SPECIAL EXAMINATIONS 

Examination of Urine and Stools. — An examination of the urine 
should be made, if possible, in every case; some obscure conditions may be 
cleared up in this way. It is impossible in an individual case to decide 
from other symptoms as to the necessity for examining the urine. This 
examination should include the presence or absence of bile, indican, indol- 
acetic acid, albumin, the acetone bodies, pathological crystals, pus, patho- 
logical epithelium, blood and casts of various kinds. 

Intestinal discharges should be inspected as a routine measure in 
all cases. This is especially important in children under two years of age. 
These discharges should be seen by the physician, as it is impossible for him 
to get accurate information concerning their character from the descrip- 
tion of them given by the nurse. The following points should be observed : 
the reaction (if strongly alkaline protein putrefaction is indicated, if highly 
acid carbohydrate fermentation) ; the consistency — watery, spongy, pasty or 
formed ; the color — green, yellow, brown, black or mottled ; the presence or 
absence of curds (which if small and soft indicate undigested fat, if large 
and tough undigested casein) — other undigested food, mucus, blood and 
intestinal parasites. In some instances it may be necessary to make a 



SPECIAL EXAMINATIONS 



35 



microscopical or chemical examination of the stools for the purpose of 
determining the presence or absence of blood, undigested food, the eggs of 
intestinal parasites, tubercle bacilli and pus. 

Talbot says : "A microscopic examination of the stool gives very accu- 
rate information about the digestion of fat. Two stains are used, one on 
each of two coverglass preparations, alcoholic solution of Sudan III 1 and 
carbolfuchsin. 2 These stain the neutral fats, fatty acids and. soaps differ- 
ently. The following table shows these differences: 



Stain 


Neutral Fat 


Fatty Acids 


Soaps 


Sudan III 


Drops staining red 


Drops staining red or crystals 
which may or may not stain 


Do not stain 


Carbolfuchsin 


Do not stain. Remain oily, 
colorless drops 


Stain brilliant red 


Stain dull red 



"After these two coverglasses are examined and the microscopic picture 
is clear, a drop of glacial acetic acid is allowed to run under the coverglass 
covering the Sudan III stain, is thoroughly mixed in, then heated until it 
begins to bubble. Care should be taken not to boil the preparation so much 
that all the melted fat will run off the slide. This process turns the soaps 
and neutral fats into fatty acids, which, while warm, appear as large red- 
stained drops, and, upon cooling, crystallize. This shows the amount of 
total fat in the stool, while the first two slides examined show the relative 
proportions of neutral fat, fatty acids and soaps. There is no way of dif- 
ferentiating neutral fat drops from fatty acid drops by Sudan III; it is, 
therefore, necessary to stain a second preparation with carbolfuchsin (see 
table) which does not stain neutral fat and does stain fatty acids. These 
tests are very simple, quick and valuable, giving accurate and often surpris- 
ing evidence concerning the digestion of fat. They should always be used. 
An excess of fat can be easily determined and acted upon; absence of fat 
very often shows why the baby does not gain and always means that fat is 
not the cause of the indigestion. This rough method of estimating the 
relative proportion of neutral fats, fatty acids and soaps also gives an idea 
of the digestive functions. If there is an excess of fat most of which is 
split the digestion is normal and assimilation is abnormal ; if the majority 
of the fat is unsplit or only partially digested both digestion and assimila- 
tion are abnormal." 

Tuberculin Skin Reactions.— The reaction which results from inoculat- 
ing the skin with Koch's old tuberculin has in recent years been very ex- 
tensively used in the diagnosis of concealed forms of tuberculosis. These 
tests are of special value in childhood, since this is the period of life when 
latent or concealed tuberculosis of lymphatic and other tissues is so common. 

1 Sudan III powder, 95 per cent, ethyl alcohol. Saturated solution. 

2 Carbolfuchsin, such as is used in staining for tubercle bacilli. If the stain 
is too intense it may be diluted with equal parts of alcohol, 95 per cent. 



36 EXAMINATION OF THE SICK CHILD 

The value and limitation of these tests are described in the chapter on 
Tuberculosis. The Moro inunction test is the simplest and the best for 
general use. In this test an ointment consisting of equal parts of anhy- 
drous lanolin and "old" tuberculin is thoroughly rubbed into a portion of 
the skin about the size of a dollar; the abdomen is the site commonly 
selected. On the opposite side of the abdomen, in a similar location, pure 
lanolin is rubbed into the skin in the same vigorous manner; this is done 
as a control. A positive reaction is indicated by the appearance within 
twelve or twenty-four hours of an eruption over the area of skin into which 
the tuberculin was rubbed, while the skin on the opposite side into which 
the lanolin was rubbed remains normal. This eruption consists of small 
papules surrounded by a red areola, so that the whole area of the spot 
rubbed, and perhaps a portion of the surrounding skin, has an erythematous 
flush in which there is a maculopapular eruption. Von Pirquet's test is 
perhaps slightly more sensitive than the Moro test. It consists in scari- 
fying the arm in three places, several inches apart ; the scarification is made 
as in vaccination. Into the middle scarification Koch's "old*' tuberculin is 
scratched or rubbed with the same technique used in Jennerian vaccination. 
A positive reaction is indicated by the appearance, within twelve or forty- 
eight hours, of an eruption of scattered papules within a dark, red zone, 
which occurs in and about the middle scarification, while the upper and 
lower scarifications show no reaction whatever. The inflammatory flush of 
the skin, which results from both the Moro and Von Pirquet tests, begins 
to subside within twenty-four or thirty-six hours after their appearance 
and thereafter quickly disappears. The severity of this skin reaction is not 
an indication of the extent or activity of the tuberculous process. A very 
pronounced reaction may be obtained in children who show no other signs 
of tuberculosis, and a negative reaction is commonly obtained in cases 
where the tuberculous process is active and associated with high fever and 
other signs of a destructive tuberculosis. The hypodermic injection of 
tuberculin and the dropping of a tuberculin solution in the eye will also 
give a prompt reaction in the latent and concealed forms of tuberculosis, 
but these tests have now largely fallen into disuse because the Moro and 
Von Pirquet tests are simpler, less disagreeable and are followed by abso- 
lutely no untoward results. 

The chief objection to all of these tuberculin tests is that they are so 
sensitive that they give a reaction in all cases where there is the slightest 
focus of concealed tuberculosis. A negative reaction is of great value in 
excluding concealed forms of tuberculosis not associated with fever and 
other acute symptoms. A positive reaction is also of great diagnostic value 
in children, but the activity and extent of the tuberculous process must be 
determined by other signs and symptoms. It is evident, therefore, that, of 
these tuberculin reactions, the least sensitive will be of the greatest value 
from a clinical standpoint. The Moro test is slightly less sensitive than 
the others and for this reason it is of more practical value from a clinical 
standpoint. 



PLATE I. 






The Moro Tuberculin Skin Reaction. 
(From Hamill, Carpenter and Cope). 



SPECIAL EXAMINATIONS 



37 



Blood Examinations. — The ordinary blood examination should include 
an estimation of the amount of hemoglobin, the number and character of 
the red blood corpuscles, the color index, the number of white blood cor- 
puscles and a differential count in which the relative percentages of the 
various kinds of white blood corpuscles are given. Such an examination is 
absolutely necessary to the diagnosis of diseases of the blood and of the 
blood-forming organs and is of great value in the diagnosis and prognosis 
of septic processes and of some of the acute infections. 

Lumbar Puncture (Quincke). — A bacteriological examination of the 
cerebrospinal fluid obtained by lumbar puncture is of great value in the 
differential diagnosis of the various forms of meningitis. The operation is 
to be performed with clean instruments under aseptic conditions so that the 




Fig. 6. — Position for Lumbar Puncture. 



fluid when obtained will not be contaminated. In performing this opera- 
tion general anesthesia, as a rule, is not necessary. The patient is placed 
on his side with his spine curved so as to bring prominently into view the 
spinous processes, and in this position he is to be firmly held by an assist- 
ant. The skin over the site of puncture is to be scrubbed with soap and 
water and washed with alcohol and a bichlorid of mercury solution. The 
operator then, with clean hands, inserts between the third and fourth lum- 
bar vertebrae a clean trocar or cannula, about one millimeter in diameter, and 
by gentle pressure it is pushed directly inward for about three-fourths of 
an inch. If it meets with an obstruction it is to be withdrawn and rein- 
serted. The entrance to the spinal canal is noted by the lack of resistance 
and by the flow of the fluid through the cannula. After the first few drops 
have escaped, from 20 to 40 c. c. of cerebrospinal fluid is allowed to flow 



38 THERAPEUTICS OF INFANCY AND CHILDHOOD 

through the cannula and is caught in a sterile test tube. The needle is now 
withdrawn, the wound dressed with surgeon's adhesive plaster and the fluid 
subjected to a careful bacteriological examination, to determine if possible 
the microorganism causing the disease. The point of puncture is located 
by an imaginary line, passing directly backward over the spine between the 
iliac crests. With the child in position, the iliac crests on either side may 
be easily located, and the line passing between these two points directly 
backward over the spine crosses the third lumbar spine; the needle is in- 
serted in the interspace below this spinal process. This operation is com- 
paratively simple and is attended with little or no danger unless it be post- 
poned until the child is in extremis. 

Rbntgen-Rays. — The pictures produced by Rontgen-rays are of the very 
greatest value in the accurate diagnosis of a large number of medical and 
surgical conditions, and the diagnostic field which has been opened up by 
this method is gradually becoming wider and wider. They are of special 
value in the diagnosis of the following conditions : injuries and diseases 
of bones and joints; kidney and bladder stones; foreign bodies in the in- 
testinal canal, respiratory passages and other organs and tissues; diseases 
of the heart and lungs; enlargement of organs, such as the thymus gland, 
kidneys, liver, and deep-seated lymph nodes; collections of pus and other 
fluids in the pleural cavity, the pericardium, accessory sinuses of the face, 
the abdominal cavity and other parts of the body. 

Other Examinations. — There are many other special examinations which 
may be necessary to clear the diagnosis in individual cases, such as the 
Widal reaction for the differential diagnosis of typhoid from other fevers; 
a bacteriological examination of the sputum for the purpose of determining 
the character of the infection in diseases of the respiratory passages; a 
bacteriological examination of the throat to distinguish diphtheria from 
other exudative inflammatory deposits; a bacteriological examination of in- 
flammatory exudates in the pleura and other parts of the body, for de- 
termining the causative organism which has produced the infection. 



CHAPTER IV 
THEKAPEUTICS OF INFANCY AND CHILDHOOD 

Under this heading may be included all measures employed for the cure 
and prevention of disease. Diet, especially during infancy, is one of our 
most important therapeutic measures, but this is elsewhere discussed. It 
remains for us here to give an outline of other methods of treatment. 

MEDICINAL TREATMENT 

Drug Administration by Mouth. — This is an important part of general 
therapeutics. By the administration of drugs a few diseases are cured; 



MEDICINAL TREATMENT 39 

many others are .treated symptomatically so that symptoms are relieved, and 
the general course and character of the disease so modified that its dura- 
tion is shortened and the chances for a favorable termination enhanced. 

In almost all diseases the use of drugs is more or less indicated, either 
for their direct curative power, their favorable influence on the course and 
duration of the disease, or their control over disagreeable symptoms. Great 
as is the value of drugs skilfully and judiciously administered, the unneces- 
sary and unskilful giving of medicines is almost of equal harm. Drugs 
should be given only when there is a decided probability that their adminis- 
tration will do the patient more good than harm. This rule of action is 
especially applicable to children under two years of age. In every sick 
infant, whatever may be the cause of its illness, the probability of gastro- 
intestinal complications should be kept in mind. It is most important that 
the physician in giving drugs, during this period of life, should exercise the 
greatest precaution lest he produce some gastrointestinal disturbance and 
thereby add a serious complication to the existing malady. This precau- 
tion is especially important in the treatment of acute diseases of the res- 
piratory passages and other acute infections. In these conditions I believe 
that infants are unwisely and unnecessarily medicated with opium, coal- 
tar products, nauseating syrups, such as ipecac and squills, and irritating 
ammonia preparations; all of which are of little or no value in the treat- 
ment, but, on the other hand, are capable of producing gastrointestinal and 
other complications which add a gravity to these diseases which they would 
not otherwise have had. In children under two years of age, and perhaps 
I may say in children of all ages, the physician before prescribing a drug 
should feel assured that there is a reasonable probability that the drug will 
exercise a favorable influence on the disease without producing harm in 
some other direction. 

Palatable medication is one of the keynotes to success in pediatric prac- 
tice. It is important that the most cordial and friendly relationship should 
exist between the physician and his little patient. Without this the physi- 
cian falls short of having his visits and his ministrations accomplish the 
greatest possible amount of good to the child. The degree of friendship 
which exists between the physician and his small patients is largely a mat- 
ter of his own making. If in his absence he instructs the mother to use 
her powerful influence over the child, to educate it into the belief that the 
physician's coming is an event to be looked forward to with pleasure, and 
if when the physician makes the visit he exercises the proper tact in his 
association with the child and uses his best judgment in the selection of 
proper remedies, which are either pleasant to the taste or their disagree- 
ableness so disguised that the child will not associate anything unpleasant 
with the taking of medicines, then the relationship of the child and physi- 
cian will be such that he can make his examinations and prescribe his treat- 
ment without engendering the child's ill-will. 

The physician should remember that pleasant medication appeals to the 
mother almost as much as it does to the child. The forcing of disagreeable 



40 



THEKAPEUTICS OF INFANCY AND CHILDHOOD 



medicines down the throat of a screaming and struggling child is an opera- 
tion which neither the mother nor the child will submit to for any great 
length of time. A procedure of this kind in children who are acutely ill, 
and especially in nervous children, exercises a very unfavorable influence 
on the course of the disease, and the drug that produces more good than 
harm under these conditions must have a specific curative influence on the 
disease. While much stress is laid upon the necessity for pleasant medica- 
tion and the tactful handling of the child so that a cordial relationship 
may exist, yet in following this line of action it is most important that the 
physician should not fail to make necessary examinations because they are 
unpleasant to the child ; nor should he omit to give it some drug having a 
specific curative influence, such as quinin, mercury or antitoxin, simply 
because by its administration he may engender the ill-will of the child. 

Opium is rarely to be administered to infants and children under two 
years of age. It may very occasionally be necessary to prescribe it during 
the second year of life for severe pain, such as occurs in earache. It should 
always be given with great caution and in small doses to children under 
five years of age. 

Syrups of all kinds are contraindicated in infancy and are seldom neces- 
sary in children under five years of age. The only exception to this rule 
is perhaps in those cases where emetics are urgently indicated. As a 
vehicle for other medicines, glycerin, essence of pepsin and elixir of lactated 
pepsin are just as palatable as syrups, and are not as likely to disturb the 
stomach and cause intestinal fermentation. Quinin may be given in the 
form of euquinin or mixed with powdered chocolate to young children; 
older children may take it in the form of pills and capsules. 

The following table gives the average dose and most common therapeutic 
indications of the drugs most frequently used in the treatment of diseases 
in children under three years of age : 



Drugs 



Dose at 
1 Year 



Dose at 
3 Years 



Therapeutic Indications 



Antipyrin 

Aspirin 

Belladonna tinct 

Bismuth subnitrate . . . 

Calomel 

Cascara sagrada ext... 

(aromatic) 
Castor oil 

Chalk comp. mixt .... 

Chloral hydrate 

Codliver oil 

Diastase 

(thick malt ext.) 

Digitalis tinct 

Guaiacol carbonate . . . 

Glonoin (nitroglycerin) 

Hydrochloric acid dil . 
Iron sach. carb 



ST. 


V?-l 


gr. 


y?.-i 


m 


y?-i 


gr. 


2-5 


gr. 


K-l 



5-10 



dr. 1 



1 
1-2 



1 
1 

400 
1 
1 



1-2 
1-3 
1-2 
3-10 
1-2 
10-20 



dr. 1-2 



1-2 
2-3 
1 



2-3 
1 1 

300 200 
2-3 
2 



Nervous symptoms associated with fever. 
Influenza, fever, nervous symptoms. 
Coryza, pharyngitis, bladder irritation. 
Gastrointestinal irritation, diarrhea. 
Gastrointestinal disorders, febrile diseases. 
Constipation. 

As a preliminary cathartic in gastroin- 
testinal disorders; acute febrile dis- 
eases. 

Gastrointestinal irritability. 

Convulsive disorders. 

As a general tonic in nutritional disorders, 
such as rickets and tuberculosis. 

As a digestive and tonic in nutritional 
disturbances, such as chronic intestinal 
indigestion. 

As a heart tonic in cardiac and other dis- 



Gastrointestinal disorders, tuberculosis. 
In condition of collapse and cardiac 
failure. 

Gastrointestinal disorders. 
Anemic conditions. 



MEDICINAL TEEATMEIS T T 



41 



Drugs 



Ipecac syrup 

Magnesia, milk of . . 
Magnesium sulphate 

Mercury with chalk 

Mercury bichlorid . . 

Morphin sulphate . . 

Paregoric 

Pepsin essence 

Phenacetin 

Potassium bromid . . 

Potassium chlorate . 
Quinin sulphate . . . . 

Euquinin 

(tasteless quinin) 
Rochelle salts 

Salol 

Santonin . . .' 

Sodium benzoate . . . 
Sodium bicarbonate 

Sodium bromid 

Sodium iodid 

Sodium phosphate . . 

Sodium salicylate . . . 

Strophanthus tinct . 

Strychnin sulphate . 
Urotropin 



Dose at 
1 Year 



dr. y 2 -i 



1 
10-20 



150 

1 



100 
5-10 



dr. V 2 



\4-l 

2-3 



1 

H 

l 

10-20 
1-2 

H 

1-2 

2-3 

2-3 

1 

5-10 

1 

1 

1 



500 

y 2 



Dose at 
3 Years 



dr. 1-2 



1-2 

30 

14-1 
l l 

100 50 

1 

40 
10-20 



1-2 
3-5 

2-3 
1-2 
3-5 

30-60 

2-4 

K-l 
3-5 
5-10 

5 
2-3 

20-30 

2 
2 

1 

200 
1-3 



Therapeutic Indications 



As an emetic in spasmodic croup and 

other conditions. 
As a laxative and stomach sedative. 
As a cathartic in nephritis and other 

conditions. 
Syphilis and gastrointestinal disorders. 

Syphilis. 



Severe convulsive disorders. 
(Given hypodermically) 

Earache and other severe pain; rarely in 
intestinal disorders. 

Digestive disorders, as vehicle for other 
medicines. 

Fever and associated nervous symptoms. 

Nervous symptoms and as a cough seda- 
tive. 

Stomatitis. 

Malaria, influenza and as a general tonic 

Malaria, influenza and as a general tonic. 

As a cathartic in nephritis, enteritis and 

other conditions. 
Gastrointestinal diseases, influenza and 

febrile conditions. 
Intestinal worms. 

Influenza and other febrile conditions. 
Stomach disorders and autointoxications 

(acidosis) . 
Nervous symptoms, cough sedative. 
Syphilis. 
As a laxative in gastrointestinal disorders, 

autointoxications and other conditions. 
Intestinal fermentation, rheumatism and 

tonsillitis. 
Cardiac disease, pneumonia and condi- 
tions producing heart failure. 
Pneumonia, myocarditis and conditions 

requiring a respiratory stimulant and 

general tonic. 
Pyelocystitis and conditions requiring a 

urinary antiseptic. 



Inunctions. — The value of this method of administering drugs to in- 
fants and children is, I believe, not fully appreciated by the general prac- 
titioner. In the following outline I have quoted freely from a paper 1 on 
this subject which I published some years ago. 

Inunctions are very much more efficacious in the treatment of disease in 
young children than they are in adults, for the following reasons : 

1. In infants and young children the surface of the skin, in proportion 
to the body weight, is from four to six times greater than in adults. This 
brings the whole blood and lymph circulation in closer communication with 
the blood vessels and lymphatics of the skin, and makes it possible for 
drugs which are rubbed into the skin to pass quickly through the body and 
make their appearance in the urine, feces, bronchial mucus and other excre- 
tions. 

2. In infants and young children the vasomotor mechanism is much 
more responsive to reflex stimuli than it is in adults, and for this reason 
the capillary circulation of the skin is made much more active by the appli- 
cation of heat and friction, as in the giving of inunctions. This facilitates 






1 Amer. Jour, of Med. Sciences, Jan., 1909. 



42 THERAPEUTICS OF INFANCY AND CHILDHOOD 

absorption and the ready introduction of medicines into the general cir- 
culation. 

3. All lymphatic structures, including those of the skin, are relatively 
more active and functionally more important in the young child than they 
are in the adult. This facilitates the ready introduction of medicines 
through the skin into the lymphatic circulation. 

4. In infants and young children nutritional problems are of vastly 
greater importance than they are in the adult, and for this reason it is of 
the utmost importance that the stomach and gastrointestinal canal should 
be kept in the best possible condition; consequently all drugs that can be 
advantageously administered in some other manner should be kept out of 
the stomach. This is especially true of drugs which are intended to influ- 
ence general metabolism and to act upon diseased tissues remote from the 
gastrointestinal canal. 

5. The disorders which can be treated most satisfactorily by inunctions, 
such as diseases of the lymphatic structures and respiratory passages, are 
much more common and much more severe in infants and young children 
than they are in adults. This fact very materially enhances the relative 
importance of the inunction treatment at this age. 

6. Experiments demonstrate that certain medicines may be introduced 
into the circulating media of the body with great facility by inunctions, 
and that this result is more readily accomplished in infants and young 
children than it is in adults. 

In the giving of inunctions the following technique should be observed. 
The skin of the chest and abdomen must be carefully washed with soap and 
warm water, and hot moist towels applied for a few minutes to warm and 
redden the skin. One drachm of the ointment should then be very care- 
fully and gently rubbed in, for a period of five or ten minutes. 

By this method I have demonstrated that guaiacol, iodin, oil of winter- 
green and salicylic acid can be readily rubbed through the skin, appearing 
in the urine of the child from one and one-half to two hours after its appli- 
cation, thus showing that these drugs have passed through the blood and 
circulating media of the child, and have come in contact with its organs 
in every part of the body. The inunction method therefore is eminently 
fitted for the administration of these drugs in all diseases where they arc 
indicated. Guaiacol, given in this way, may be used in the treatment of 
tuberculosis, influenza, bronchitis, bronchopneumonia and all diseases of 
the respiratory passages, and should to a large extent take the place of such 
expectorants as ammonia, squills, ipecac, and antimony. These latter 
drugs are not only of little or no value in the treatment of these diseases 
in infants, but they are capable of producing grave complications on the 
part of the gastrointestinal organs. Iodin administered by inunction is of 
positive value in the treatment of late syphilis, chronic glandular enlarge- 
ments and subacute and chronic diseases of the respiratory passages. Oil 
of wintergreen and salicylic acid, given by inunction, are very valuable in 
the treatment of muscular rheumatism, acute and chronic articular rheu- 



OTHER METHODS OF TREATMENT 43 

matism, chorea, tonsillitis, and endocarditis. The inunction method of ad- 
ministering mercury (blue ointment) has long been recognized as the safest 
and best method of administering this drug in the treatment of syphilis in 
young infants, and requires no elaboration here. Colloidal silver, within 
the past few years, has been administered hypodermically, by the stomach, 
and by inunction in the treatment of various forms of localized and general 
septicemias. The profession as a whole, I think, has come to recognize 
that this is a most valuable adjunct in our treatment of septicemia, and I, 
for one, after a large experience extending over a number of years, am 
firmly convinced of its efficacy. In acute enlargement of the lymphatic 
tissues of the neck, which may follow scarlatinal, diphtheritic and other 
forms of tonsillitis, I believe that this remedy, in the form of unguentum 
Crede, properly rubbed into the surrounding lymphatic tissues, is of very 
great value in preventing the spread of the disease and in controlling the 
localized sepsis. This drug can be given more efficaciously to infants and 
young children by inunction than in any other manner, and its value in 
combating general and localized sepsis is much greater in infants and chil- 
dren than it is in adults. 

Ouaiacol, iodin, oil of wintergreen, and salicylic acid, for inunction 
purposes, should be combined with anhydrous lanolin in the proportion of 
one drachm to the ounce, and the dosage of the ointment thus prescribed 
should be one small level teaspoonful thoroughly rubbed into the skin once 
or twice in twenty-four hours. Unguentum Crede should be given in the 
same dosage at least twice a day for a period of three or four days, and it 
is most important that it should be applied over a large surface of the 
body and should be thoroughly rubbed in. 

OTHER METHODS OF TREATMENT 

The giving of medicines is a comparatively small part of the physician's 
duty. The questions of prophylaxis, diet, general hygiene, hydrotherapy, 
and special methods of treatment are more important than drug giving 
except in those comparatively few diseases for which we have specific medi- 
cation. The giving of drugs should be considered as a valuable adjunct to 
other methods of treatment. This is especially true in the gastrointestinal, 
the respiratory and the acute infectious diseases, which make the vast 
majority of the illnesses of infancy and childhood. It is not my desire to 
belittle the importance of drug giving, but rather to emphasize the relative 
importance of other methods of treatment. 

Fresh Air. — Fresh air is one of the most important curative agents we 
have for the treatment of disease. As Northrup has said, we mean by 
fresh air outdoor air, cool, flowing air, that is to sa} r , the very freshest air 
which the child can obtain in the location in which it is being treated. The 
outdoor air which may be obtained on porches, and which comes into the 
sickroom through wide-open windows even in the downtown tenement dis- 
tricts of our large cities, is better than the indoor air, but it is not as good 



44 



THEKAPEUTICS OF INFANCY AND CHILDHOOD 



as the outdoor air which can be obtained in the suburbs of our cities and 
in the surrounding country, and it is nothing like as good as the pure, open 
air of the mountains, seashore, and other locations far removed from the 
contaminating influences of cities. In the treatment of gastrointestinal 
and respiratory diseases the curative influence of pure, fresh, flowing air 
is of far greater value than drugs, and it is also of prime importance as a 
remedy in the treatment of almost all diseases of infancy and childhood. 
If the physician but realizes the importance of fresh, pure air as a thera- 




Fig. 7. 



-Fresh-Air Ward Established by the Author at the Cincinnati Hospital in 

1898. 



peutic agent, his own common sense and judgment will direct him in ar- 
ranging the details for the carrying out of this treatment. As Northrup 
has emphasized, this remedy should be given in large doses and throughout 
the whole of the twenty-four hours, but in doing this the physician must 
so instruct the mother and the nurse in such details as clothing, bedding 
and the location of the patient, either in the open or in rooms with wide- 
open windows, that while the child is getting the required amount of fresh 
air it may be kept warm in winter and cool in summer. In the chapter on 
Respiratory and Gastrointestinal Diseases further details as to this treat- 
ment are given. 

Hydrotherapy. — Hydrotherapy in its various forms is one of the most 
valuable curative agents we have in the whole range of therapeutics. When 
water is applied to the surface of the body it reduces the temperature by 
abstracting heat and promoting evaporation; it stimulates the skin to in- 
creased activity ; it acts kindly in controlling nervous symptoms, and, above 



OTHEE METHODS OF TREATMENT 45 

all, it has a general tonic effect, stimulating nutritional processes. In this 
it differs markedly from medical antipyretics. 

Tub-baths. — Tub-baths have a wide range of applicability in the treat- 
ment of diseased conditions in infancy and childhood. Children, however, do 
not bear very cold tub-baths as well as adults, their young nervous systems 
are shocked by the sudden application of cold, and they do not readily react 
from the cold bath. It is advisable, therefore, to begin with a temperature 
of 100° F. and gradually add cold water until the temperature of the bath is 
reduced to from 80° to 90° F., according to the age of the child. In 
infants it is rarely necessary to reduce the temperature of the water below 
90° F. In older children it may be reduced to 80° F. The patient should 
remain in the bath from five to ten minutes and then be rubbed dry and 
returned to bed. This remedy is especially indicated in the gastrointes- 
tinal diseases of infancy and is also of value in the treatment of typhoid 
fever, pneumonia, and other diseases in which the temperature runs high 
and is associated with nervous symptoms. 

Sponge Baths. — These baths, when properly applied, reduce the tem- 
perature, quiet the nervous system, promote sleep, and have a tonic effect 
upon nutritional processes. They have much the same range of applica- 
tion from the therapeutic standpoint as the tub-bath. While somewhat 
less efficacious than the tub-bath, they have the advantage of being more 
easily administered and of producing less shock and excitement to the 
nervous system. In their application a rubber sheet should protect the bed, 
and on this the child, after having its clothing removed, is placed between 
two blankets. The entire body of the child is then sponged with water at 
80° F. containing 5 or 10 per cent, of alcohol. During the sponging process, 
which may be continued for ten minutes, the parts of the body not being 
sponged are to be covered, so as to prevent unnecessary chilling of the body. 
The therapeutic effects of this measure are due not only to the application 
of cold water to the surface of the body, but to the rapid evaporation which 
is thereby promoted. 

Cold Packs. — This is a measure used for the same therapeutic purposes 
as the tub and sponge baths. It has its widest range of applicability, how- 
ever, in older children. It is a very effective measure for the reduction of 
high temperatures. The body of the child is surrounded with a sheet 
wrung out of water at about 90° F., and over this sheet, which clings closely 
to the child's body, ice is rubbed. This procedure may be continued for 
from ten to twenty minutes, depending upon the influence which the cold 
pack has upon the rectal temperature and upon the general condition of 
the child. During this process an icebag should be applied to the head. 
This bath may be modified by sprinkling the sheet with cold water from 
time to time, and fanning the body of the child so as to promote evapora- 
tion. Following these measures, the child is to be wrapped, sheet and all, 
in a blanket, a warm water bottle placed to its feet, while the icebag to 
the head is to be continued. After one-half hour the child is to be dried 
and returned to its bed. 



46 THERAPEUTICS OF .IN^A^GY AND CHILDHOQD \ : > 

The cold pack, cold sponging, or tub-bath may be repeated at intervals 
of from four to eight hours if necessary for the control of the temper- 
ature. It should, however, be remembered, as I have emphasized in the 
chapter on Fever, that children bear moderate and even high temperatures, 
as a rule, without serious inconvenience, and that unless the fever continues 
high and is associated with nervous and other symptoms it is not advisable 
to be too energetic in our efforts to reduce temperature. Where temper- 
ature reduction, however, is indicated as a therapeutic measure hydro- 
therapy in one of the forms above described is to be preferred to medical 
antipyretics. 

Icecap. — Cold applied to the head in the form of an icecap is a simple 
and effective measure for reducing temperature, relieving headache and 
quieting general nervous symptoms. The icebag is of great value in the 
treatment of sunstroke, meningeal inflammation, acute inflammatory con- 
ditions of the heart and its membranes, appendicitis, acute parenchymatous 
tonsillitis, and in acute localized, congestive and inflammatory lesions in 
various parts of the body. In*" very young and delicate infants it should 
be cautiously applied, but apart from this it is a comparatively safe meas- 
ure, productive of much good and rarely followed by untoward symptoms. 

Cold Compresses. — Cold compresses, made by wringing a towel out of 
water of 75° or 80° F., and covering it with dry flannel, has the same 
therapeutic indications as the icebag. This measure is sometimes of con- 
siderable advantage in inflammatory diseases such as tonsillitis, pneumonia, 
pleurisy and endocarditis. 

Hot Baths. — The hot bath is of great therapeutic value in the treat- 
ment of uremia, infantile convulsions, delirium and coma. It also has 
a very soothing and tonic effect in bronchopneumonia. It is one of our 
most effective measures for eliminating toxins in the acute infectious dis- 
eases and in the various forms of autointoxication. The child should re- 
main in water of 110° F. for from five to twenty minutes, and should then 
be wrapped in a hot blanket for one-half hour. Following this it should be 
thoroughly dried and returned to bed. 

Hot Compresses. — Hot compresses are of great therapeutic value in 
muscular rheumatism (lumbago), neuralgic headaches and other super- 
ficial neuralgias, abdominal pain and localized inflammations. They 
should be applied by wringing towels out of very hot water and placing 
these as hot as they can be borne to the affected part. The hot compress 
may then be covered with oiled silk and held in position with a dry towel. 

Salt-baths. — Salt-baths are of some therapeutic value in the treatment 
of rickets and other malnutritions. A pound of salt should be added to 
six gallons of water at body temperature. The bath should last for ten 
or fifteen minutes and should be followed by vigorous rubbing or gentle 
massage ; one such bath in twenty-four hours is sufficient. 

Eectal Irrigations. — Eectal irrigations with cool water are of value in 
reducing the temperature of infants suffering from heat stroke and gastro- 
intestinal disorders. A double rectal tube which permits of an in- and out- 



OTHER METHODS OF TREATMENT 



47 



flow and which can be passed well beyond the internal sphincter is to be 
used. In the beginning the temperature of the water should be about 
90° F., and should be gradually reduced to 60° F. The irrigation may last 
over a period of ten minutes. 

Water Taken by Mouth. — Water taken by the mouth reduces the 
temperature and is by far the simplest and best diuretic and diaphoretic. 
It is of the very greatest value during the first forty-eight hours in the 
treatment of all acute gastrointestinal diseases of infancy. It is indicated 
in all the acute infectious diseases, especially scarlet fever, and is of value 
in the treatment of all febrile conditions. It is of value in constipation, 




Fig. 8. — Hypodermocltsis. 



functional and nervous disorders, and all forms of autointoxication. Dur- 
ing the first year of life the infant, as a rule, gets a sufficient quantity of 
water in its food, but, should it be necessary to cut down the food during 
this period of life, the deficiency should be made up by the addition of 
water. In infancy and childhood too little attention is given to the value 
of water in the conditions above named. It should be prescribed as any 
other remedial agent in all toxic and febrile diseases. Ice is a remedy of 
value in relieving irritability of the stomach, in allaying thirst, and in 
promoting the general comfort of the patient in febrile and gastrointestinal 
diseases, where for some reason water cannot be given in quantities suffi- 
cient to meet the demands of the patient. The ice in these cases should be 
held in the mouth until it melts. In voumr infants and children it may be 



48 THEEAPEUTICS OF INFANCY AND CHILDHOOD 



necessary to inclose the ice in a piece of gauze to prevent them from swal- 
lowing it. 

Hypodermoclysis. — Hypodermoclysis, or the introduction into the sub- 
cutaneous tissue of a 0.6 per cent, common salt solution, is the most effective 
general stimulant and diuretic in all cases in which the body media is defi- 
cient in fluids. It is especially indicated in the profound prostration asso- 
ciated with acute gastrointestinal disorders (cholera infantum), severe 
cases of recurrent vomiting and severe hemorrhage. It may also be of 
value in uremia, cardiac failure, and in all cases where a powerful stimu- 
lant and diuretic is urgently indicated. One per cent, of bicarbonate of 
soda may be added to this salt solution in "recurrent vomiting" and other 
conditions where it is desirable to counteract an acidosis. The favorite 

sites for this injec- 
tion are under the 
breast and the loose 
subcutaneous tissue of 
the back and abdo- 
men. The salt solu- 
tion should be sterile 
and should be intro- 
duced through a sterile 
needle under full asep- 
tic precautions. In in- 
fants and children 
from six to ten ounces 
may be introduced at 
one time. If this is 
quickly absorbed the 
injection may be re- 
peated, if necessary, 
within six or eight 
hours. The same 
strength of lukewarm 
salt or soda solution in cases of persistent vomiting may be of great value 
when introduced through a soft catheter into the colon, where it is readily 
absorbed. In this procedure the catheter may remain in position and the 
fluid be allowed to slowly escape by the drop-method or small injections 
may be repeated from time to time. 

Nasal Douche. — Washing out the throat, nose, and pharynx with a mild 
alkaline antiseptic solution is, as Caille has emphasized, a measure of great 
prophylactic and curative value in diseases of these parts. The prophy- 
lactic value of this process in the prevention of all contagious diseases 
which affect the throat and respiratory passages, as well as of many other 
diseases, is not fully appreciated by the medical profession. In washing 
out the nasopharynx the child should sit upright, with its head inclined 
slightly over a basin. The mother or nurse, with an all-soft rubber nose 




Fig. 9. — Position for Nasal Douching. 



OTHER METHODS OF TREATMENT 49 

syringe, slowly injects the alkaline solution backward through the nose. 
By this procedure some of the solution comes out of the other nostril and a 
portion of it is carried downward through the pharynx into the mouth and 
is expectorated by the child into the basin. The direction of the tip of the 
syringe which enters the nostril should be almost directly backward. By 
this method mucus and mucopurulent secretions may be washed out of these 
parts, and their absorption thereby largely prevented. The danger of forc- 
ing fluid through the Eustachian tube into the ear and thereby causing an 
internal ear complication is slight as compared with the danger of infection 
from the purulent material if it is not dislodged and the inflammation 
modified or controlled by irrigation. Atomizers may be used for the same 
purpose, but they are much less effective than the nasal douche in the 
cleansing of the nasopharynx. 

Stomach Washing (Lavage). — This therapeutic measure, introduced by 
Epstein, is of value in selected cases. Its value and range of application, 
however, are not so great in the child as they are in the adult. The older 
child is commonly so terrified by this measure that the resistance which it 
offers makes lavage of doubtful efficacy in all except the most urgent con- 
ditions, such as poisoning, or in conditions of unconsciousness, where even 
in the older child the tube may be introduced without resistance. In young 
infants, however, the ease with which this procedure is carried out gives it 
a much wider range of application. Its chief indication is for the relief of 
gastric irritability and for removing poisons from the stomach. It is ur- 
gently indicated in all cases of poisoning at any age and is of value for 
the relief of persistent vomiting associated with gastritis, chronic gastric 
indigestion, and pyloric spasm. This method, even in these cases, however, 
should not be abused. If the stomach is once thoroughly washed out and 
allowed to rest for four or five hours, water, with perhaps the addition of 
a little lime water, may be given for a number of hours until the gastric 
irritability has subsided, and then properly selected foods will be retained 
if the case be one of simple gastric irritability. If the vomiting persists 
after this careful procedure the case is probably one in which repeated 
stomach washings will be of little or no value. 

The apparatus used consists of a funnel attached by means of soft rubber 
tubing to a No. 12 American catheter. A small piece of glass tubing is 
used to connect the rubber tubing with the catheter, so that the flow of 
fluids to and from the stomach may be observed. The child is to be wrapped 
in a sheet or blanket inclosing its arms and legs so that it may be firmly 
held by an attendant. It may be placed on a table, flat on its back, or may 
be held in a sitting posture, with its head upright against the body of the 
nurse. The finger of the left hand is now introduced into the mouth, de- 
pressing the tongue, and with the right hand the catheter is introduced 
into the esophagus and directed downward into the stomach. In the young 
infant there is no difficulty whatever in this procedure. The catheter on 
gentle pressure finds its way, without accident, into the stomach. The in- 
fant's mouth may be held open by holding the index finger between its 



50 



THERAPEUTICS OF INFAXCY AND CHILDHOOD 



gums, and if it has both upper and lower incisors the catheter is to be 
pushed to one or the other side, so that the teeth will not impinge upon it. 
When six or seven inches of the catheter have been introduced, the funnel 
should be depressed for the purpose of siphoning out the contents of the 
stomach. A common salt solution (teaspoonful to the quart) or the same 
strength of bicarbonate of soda solution at a temperature of 100° F. may 
now be poured into the funnel, which is elevated to a sufficient height to 
allow the fluid to flow slowly into the child's stomach. When the stomach 

is full, as indicated by the 
contents of the funnel, 
both the funnel and tube 
should be depressed to a 
point which will allow the 
contents of the stomach to 
be siphoned off. This 
process is to be repeated 
a number of times, until 
the water which is siphoned 
from the stomach is clear, 
indicating that the stom- 
ach has been cleansed. If 
after introducing the tube 
into the stomach no fluid 
is returned, it is possible 
that the catheter has been 
obstructed by mucus or 
food. Under such condi- 
tions it is necessary to re- 
move, cleanse, and reinsert 
the catheter. In with- 
drawing the catheter from 
the stomach it is impor- 
tant to make firm pres- 
sure on the soft tubing, so 
that the fluid contained in 
the catheter may not es- 
cape into the throat and larynx during the process of withdrawal. This is 
especially important in those cases where it is necessary to insert the cathe- 
ter through the nose into the stomach rather than through the mouth. 

Gavage. — Gavage, or the introduction of food into the stomach through 
a tube, should be preceded by preliminary stomach washing. After the 
stomach has been thoroughly emptied, certain foods, such as breast-milk, 
peptonized milk, albumin water, meat juice, and certain prepared meat 
preparations, may be introduced into and left in the stomach. Kerley has 
shown that food may sometimes be retained, when introduced in this way, 
in cases of persistent vomiting in infancy. Gavage may also be indicated 




Fig. 10. — Stomach-Washing. 



OTHER METHODS OF TREATMENT 51 

in the feeding of premature infants and in severe diseases, such as pneu- 
monia, typhoid fever, and meningitis, where the condition of the patient 
makes it either impossible to administer food by the mouth, or where the 
irritability of the stomach is such that the food is not retained when given 
in this way. 

Rectal Enemata. — The value of enteroclysis, or the introduction of nor- 
mal salt solution into the colon to supply fluids to the tissues and organs 
in conditions of collapse, starvation, uncontrollable vomiting, profuse hem- 
orrhage and nephritis has been referred to under the heading Hypodermo- 
clysis. Ordinary enemata, however, are indicated for very different con- 
ditions. They have great curative value in acute and chronic enterocolitis 
and especially in those cases in which there is a marked tenesmus, with 
mucous and bloody discharges. The flushing of the colon in these cases 
with a normal salt solution washes away the fecal matter and mucus, 
exercises a local curative influence on the mucous membrane, diminishes 
the intestinal toxemia, and reduces the fever and nervous symptoms from 
which these patients suffer. 

In the giving of rectal enemata for washing out the colon, a small 
rubber catheter should be inserted six or eight inches into the bowel; it is 
not necessary to introduce the tube higher. Through this catheter, which 
is attached to an ordinary fountain syringe, salt solution, one teaspoonful 
to a quart, is allowed to flow. The quantity of fluid introduced will de- 
pend upon the individual case, and varies, in the infant and young child, 
from a pint to a quart. AYhen the catheter is removed pressure is to be 
made upon the buttocks and the child kept quietly in bed so that the fluid 
may be retained for a time, in order that it may more thoroughly dissolve 
the mucus and fecal matter and thereby more effectually cleanse the bowel. 
In giving the injection the child's position should be either on the back 
or left side, with the buttocks slightly higher than the body, and the fluid 
should be allowed to flow slowly into the bowel. 

Rectal injections of salt water are also of great value for the relief of 
constipation, and when given for this purpose the smallest possible quan- 
tity of water which will produce the desired result should be used. This 
procedure produces less irritation than any of the local measures we have 
for the relief of constipation. It is especially valuable during the first 
year of life ; in many cases it may be necessary to continue the use of small 
salt water injections over a period of many months, until the infant is old 
enough to have its constipation corrected by diet or other means. 

Kerley has emphasized the great value of injections of small quantities 
of olive oil for the relief of constipation. This -method is of special value 
in children over one year of age. From one to three ounces of olive oil 
should be injected into the colon before the child goes to bed, and should 
be allowed to remain there, if possible, over night, or until the oil excites 
sufficient peristalsis to produce an evacuation of the bowels. This is with- 
out doubt a remedy of great value in children over one year of age. 

Rectal Feeding. — Rectal feeding is nothing like so successful or so fre- 



52 THEEAPEITTICS OF INFANCY AND CHILDHOOD 

quently indicated in the child as it is in the adult. Nutrient enemata, 
however, may be of value in uncontrollable vomiting, in acute gastritis 
produced by the swallowing of caustic chemicals, and in other conditions 
where it is impossible for a prolonged period to feed the child by the mouth. 
The food materials used for this purpose are soluble peptone preparations, 
egg albumin, peptonized milk, and dextrinized gruels. It may also very 
rarely be necessary to introduce into the colon certain stimulants, such as 
whiskey, brandy, digitalis, strophanthus, and strychnin. When this be- 
comes necessary these stimulants should be well diluted with normal salt 
solution or dextrinized gruels. Eectal stimulation, however, in infancy 
and childhood is for the most part uncertain and unsatisfactory. 

Rectal Suppositories. — Eectal suppositories are very largely used and 
their use very greatly abused in the treatment of constipation in infancy 
and childhood. Soap and glycerin suppositories, which are in such general 
use, are very effective for unloading the lower bowel, but their habitual use 
is productive of much harm. These suppositories in time produce more 
or less rectal irritation and predispose to hemorrhoids and fissures of the 
anus. The rectal irritation produced by these suppositories makes the 
sphincter more irritable and by causing its contraction aggravates the con- 
stipation. Suppositories are here mentioned, therefore, chiefly for the 
purpose of condemning their habitual use. An occasional glycerin sup- 
pository may be justifiable. Gluten suppositories are much less effective 
and are much less irritating to the rectum, and may be used at infrequent 
intervals with comparatively little danger of producing disease of the 
rectum. 

Suppositories are very commonly used in the adult as a vehicle for 
giving opium, belladonna, and other remedies, but they are very rarely used 
for this purpose in the child. Collargum, however, may be very advan- 
tageously given in this way to older children in the treatment of general 
septic conditions. 

Rest and Muscular Exercise.— Eest in bed and muscular exercise are 
therapeutic measures of the greatest importance in the cure of disease. 
In order, however, that the best results may be obtained from these meas- 
ures they must be prescribed with a precision that requires more skill and 
acumen on the part of the physician than are required for the giving of 
drugs, or for the proper use of any other therapeutic measure. It should 
further be remembered that to obtain the best results the fresh air treat- 
ment must be combined with these agencies in the treatment of disease. 

Eest Cure. — Under this heading may be included rest in bed, which is 
absolutely necessary in the treatment of pneumonia, scarlet fever, typhoid 
fever, and all the acute infectious diseases. In appendicitis and acute in- 
flammatory diseases involving the peritoneum, the rest in bed must be 
prolonged until convalescence is thoroughly established. In acute nephri- 
tis the patient must be confined to bed until the urine findings are normal. 
In tuberculosis, associated with fever, the patient should rest in a reclining 
position, or in a comfortable chair in the open air, until the active tuber- 



OTHEE METHODS OF TREATMENT 53 

culous process is under control. In acute diseases of the heart, such as 
myocarditis, endocarditis, and pericarditis, prolonged rest in bed is the 
most valuable therapeutic agent we have. The temporary recovery as well 
as the future welfare of these cardiac cases depends to a large degree upon 
the skill with which the physician prescribes the period of rest and the 
gradual return to light exercise. In many of the functional nervous dis- 
orders of childhood rest in bed under quiet surroundings and under the 
careful direction of a tactful nurse is of great value. Northrup has em- 
phasized the value of this method of treatment in neurotic infants suffer- 
ing from indigestion, sleeplessness, and other nervous symptoms. 

Massage. — Massage is a valuable therapeutic agent. It gives tone and 
strength to muscles which have weakened under injury or disease; it im- 
proves the circulation in superficial muscles and other tissues ; it stimulates 
the functional activity of certain internal organs, such as the liver and 
intestines; it acts as a general tonic, stimulating normal processes of 
metabolism ; it has a sedative effect on the nervous system ; and it promotes 
the elimination of toxins, especially autotoxins. 

General massage is of special value to children when more active forms 
of exercise are contraindicated or when they are suffering from deformities 
which cannot be reached by active exercise. It may be indicated in recur- 
rent vomiting (interval treatment), general malnutritions, chronic tuber- 
culosis, chronic anemia, and in all conditions in -which the muscles of the 
child are poorly developed. It is indispensable for the proper treatment of 
spastic and flaccid paralyses associated with cerebral and spinal palsies. In 
these conditions massage is to be associated with proper orthopedic treat- 
ment, not only for developing the muscles, but for correcting the deformi- 
ties. In chronic constipation massage is of special value. In this condi- 
tion deep massage beginning at the cecum is to follow the line of the colon 
to the sigmoid flexure ; the so-called cannon-ball massage, which consists in 
rolling a covered iron ball weighing three or four pounds around the cir- 
cumference of the abdomen in the direction of the colon, is a valuable expe- 
dient in some cases. 

Passive and Resisted Movements. — Passive and resisted movements 
are of value in the correction of deformities and the development of muscles 
weakened or paralyzed by injury or disease of the nervous system. The 
contractures which occur in cerebral palsies should receive this form of 
treatment. 

Gymnastic Exercises. — Gymnastic exercises, when skilfully directed 
and carefully carried out, are of very great value in correcting spinal curva- 
tures and other deformities not due to organic disease of the bones or 
nervous system. Under a skilful physical director these exercises may give 
symmetry of development to the body. 

Breathing Exercises. — Breathing exercises, when properly done in 
the open air, increase the respiratory capacity, carry more oxygen into the 
lungs and blood, promote the elimination of carbonic acid, and thereby act 
as a general blood tonic, improving nutritional processes. 



54 THERAPEUTICS OF INFANCY AND CHILDHOOD 

It is of importance that every child should be taught how to breathe so 
as to develop his full lung capacity. This can only be done by combining 
with deep inspiration and slow expiration certain body and chest move- 
ments, which will bring into play not only the diaphragm and intercostal 
muscles, but all the accessory muscles of inspiration. If the habit of proper 
breathing is acquired during childhood it commonly becomes a habit which 
lasts through life. 

Breathing exercises are of value in undersized, malnourished children 
with poor lung capacity. They are especially indicated in chronic anemia 
and chronic tuberculosis, as well as in children who, by reason of enlarged 
tonsils and adenoids, have poorly developed chests. 

Outdoor Play. — The ordinary outdoor games, such as ball, tennis, 
skating, running, jumping, etc., are vastly superior to the forms of exer- 
cise above noted for the development of the normal child. Outdoor games 
are also of value in promoting the physical and incidentally the mental 
development of children who from heredity, environment, or chronic illness 
are below the normal in physical development. In many instances, how- 
ever, outdoor sports when directed only by the child's instincts and desires 
are too strenuous or otherwise unsuited to bring about the best results in 
development in an individual case. In such instances the physician may 
prescribe modified outdoor sports under careful supervision, and that may 
be combined with gymnastic exercises, breathing exercises, passive and re- 
sistant exercises or massage, according to the demands of the individual 
case. Exercises, manipulations, and movements to accomplish definite and 
specific results must be carried out under the direction of an instructor, 
and massage, passive and resisted movements must be intelligently done by 
one who understands the results which the physician seeks to obtain in the 
individual case. 

Psychotherapy. — In the treatment of neurotic disorders in children, as 
well as in the adult, psychotherapy is a valuable therapeutic agent. The 
young child suffering physical pain, or with wounded feelings, crying bit- 
terly, rushes into the arms of his mother, she presses him to her breast, 
kisses away his tears, and by a kind and tactful word makes him forget 
his woes, directs his plastic mind into other channels of thought and sends 
him away laughing and happy. This is an everyday example of the power- 
ful influence which suggestion may exercise over the emotional, imaginative. 
and imitative mind of the young child. By word pictures alone the im- 
aginative mind of the child may be made to see terrifying objects which 
may cause a sleepless night. On the other hand, the sleepless, nervous 
child, whose mind has been excited by an overwrought imagination or by 
undue nervous strain before going to bed, may be quieted and ofttimes put 
to sleep by reassuring words from a forceful, tactful, and sympathetic 
mother, who knows how to use the control which the unlimited confidence 
of her child has given her over its emotional nature. 

Nervous habits, such as stammering, habit-spasm, masturbation, nail- 
biting and dirt-eating, may be contracted by association with other children 



OTHER METHODS OF TREATMENT 55 

having these habits. The imitative nature of the child makes it possi- 
ble to influence its immature nervous system for good or evil by 
favorable or unfavorable surroundings. In the treatment of the above- 
named nervous habits it is important, therefore, that the patient should 
not be associated with nervous children or be under the care of a nervous, 
emotional nurse. It may be necessary to tactfully disregard or forcibly 
control certain nervous habits, or, again, it may be wise to ingenuously dis- 
claim the existence of nervous symptoms. In this manner the child may 
be surrounded by an atmosphere which will cause it to be interested in out- 
side things and less intent upon its own nervous condition. At times it 
may be necessary to separate a nervous child from its surroundings and 
place it under the exclusive care of a kind, firm, tactful nurse. The child 
very quickly realizes that it cannot enlist the sympathy of the nurse, as it 
did its mother's, by emotional outbursts. Under such conditions the kindly 
indifference, the tactful firmness, and the gentle attentiveness of the nurse 
may exercise a most helpful influence in the cure of hysterical and kindred 
neurotic disorders of childhood. It is difficult to formulate rules to guide 
the physician in the use of psychotherapy as a therapeutic measure. It is 
important to remember that children are emotional, imaginative and imi- 
tative, and that their immature minds are very receptive and easily influ- 
enced by suggestion from those in whom they have confidence. The physi- 
cian who has a good working knowledge of child nature, the skill to apply 
this knowledge in controlling the child's emotions, and the tact to accom- 
plish this through the co-operation of the mother will find many oppor- 
tunities for using psychotherapy as a therapeutic measure, not only in the 
ordinary neuroses of childhood, but in many other diseases in which nervous 
symptoms are prominent. 

Vaccine Therapy. — In 1903 A. E. Wright demonstrated the presence of 
certain substances in blood serum, which by their action so disabled bacteria 
that phagocytic cells could more easily take them up and destroy them; 
these substances he called opsonins. Previous to this discovery it was 
known that certain other bodies in the blood had the power of destroying or 
limiting the action of bacteria : "the agglutinins" conglomerated bacteria ; 
"the bacteriolysins" and "bacteriocidal substances" destroyed them. All of 
these, including opsonins, are called antibodies, because of their antagon- 
ism to bacteria and other foreign cells that happen to find an entrance into 
the body media. 

Wright believes that nature by the development of a specific opsonin for 
each bacterium makes it possible for the phagocytes to limit the course and 
modify the severity of both local and general bacterial infections. He also 
believes that both natural and acquired immunity against bacterial infec- 
tion depends much more upon the opsonic content of the blood than upon 
any of the other antibodies. These views naturally led Wright to the de- 
velopment of a method which had for its purpose the cure of bacterial dis- 
eases by artificially increasing in the blood serum of the patient the particu- 
lar opsonin which assisted in the phagocytosis of the specific microorganism 
causing the infection. 



56 THEKAPEUTICS OF INFANCY AND CHILDHOOD 

Opsonic Index. — The opsonic power, or opsonic content of an individ- 
ual patient's blood serum, when divided by the opsonic power or opsonic 
content of the blood serum of a normal individual, will give the opsonic 
index of the patient's blood serum. The opsonic index thus obtained may 
in skilful hands, as Wright has demonstrated, be of value in an individual 
case in determining the necessity for vaccine treatment, as well as the dose 
of the vaccine to be administered, and subsequently the influence which the 
dose of vaccine has had in increasing the opsonins in the blood. 

Accumulated experience with the vaccine treatment has demonstrated 
that successful vaccine therapy may be carried on without the use of the 
opsonic index, and this has brought vaccine therapy within the scope of the 
general practitioner. 

Without Opsonic Index. — In giving bacterial vaccines with no knowl- 
edge of the individual patient's opsonic index it is advisable to begin with 
a small dose. The size of the subsequent doses as well as the length of 
the interval between the treatments may then be determined by the clinical 
reaction. The "clinical reaction" is manifested by a slight rise in tempera- 
ture, a feeling of malaise, and by a slight exaggeration of existing symp- 
toms. After twenty-four hours this is followed by a fall in temperature 
and general improvement in all the symptoms. 

As a guide to the giving of bacterial vaccines without the use of the 
opsonic index, the following rules may be observed : 

1. Begin with a small dose. 

2. If no "clinical reaction" whatever occurs, and no improvement in 
the patient's condition takes place within three days, a second and larger 
dose may be given. This rule of action may be followed until a "clinical 
reaction" does occur, or until the patient commences to improve under the 
treatment. If the patient is improving under a certain dose of vaccine, 
even though no "clinical reaction" occur, the same dose should be con- 
tinued at a five to seven-day interval. Wright does not believe it advisable 
to elicit the "clinical reaction" as an indication that the size of the dose 
is sufficient. Improvement in the symptom group is a more reliable in- 
dication. 

3. If the "clinical reaction" follows the giving of a dose of vaccine 
and this is followed by improvement in the patient's symptoms, a second 
and smaller dose should be repeated in six or seven days, and this rule of 
action is to be continued as long as vaccine therapy is indicated. 

4. If a "clinical reaction" is not followed by improvement in the 
patient's condition, vaccine therapy is not indicated and may do harm in 
that particular case. 

Bacterial Vaccines. — Bacterial vaccines consist of sterile mixtures of 
dead bacteria in salt solution. Each c. c. of these vaccines contains a 
definite number of dead bacteria. The dose of the vaccine is regulated by 
the number of dead bacteria one desires to give in an individual case. There 
is as yet no way by which the potency of the dose may be accurately stand- 
ardized. One does inject a definite number of killed bacteria, but the 



OTHER METHODS OF TREATMENT 57 

potency of this dose depends not alone upon the number of bacteria in- 
jected, but also upon the virulency of the particular bacterial culture from 
which this vaccine was made. This inaccuracy in dosage, together with 
our lack of knowledge as to the manner in which an individual patient 
will react to different vaccines, makes the proper initial dose in every in- 
stance more or less problematical; for these reasons it is desirable to begin 
with small doses, which experience has taught are safe. 

The best results from vaccine treatment are obtained by the use of 
autogenous vaccines, that is to say, vaccines which are prepared from a 
culture of the individual organism causing the disease. The difficulty in 
the technique, however, makes it rarely possible for the general practi- 
tioner to use autogenous vaccines; this is possible only when he has at his 
disposal a well-equipped laboratory and the assistance of a competent bac- 
teriologist. This difficulty has brought into more or less general use the 
stock vaccines now on the market, which can in many instances be relied 
upon to produce satisfactory therapeutic results if the practitioner has the 
facilities at hand for making an accurate bacteriological diagnosis. For 
example, if it is definitely determined that a given infection is due to a 
certain staprrylococcus, or that there is a double infection in which both 
the staphylococcus and gonococcus play a part, then the physician by the 
use of the respective stock vaccines for combating infections caused by 
these organisms may hope to obtain satisfactory results. 

The safe initial dose of the staphylococcus vaccine, during the first year 
of life, is about 5,000,000 dead staphylococci; during the second year of 
life about 10,000,000 ; during the third year about 20,000,000 ; during the 
fourth year about 30,000,000 ; increasing 5,000,000 each year thereafter up 
to the tenth year of life, when it is about 60,000,000. The safe initial dose 
of the gonococcus vaccine is about one-tenth that of the staphylococcus vac- 
cine above given, and that of streptococcus and pneumococcus vaccines 
about one-fifth. 

Therapeutic Indications. — Vaccines are indicated in localized rather 
than in general infections, and in subacute and chronic rather than in 
acute infections. It would appear from the present literature on this sub- 
ject that vaccines are of value in acute general infections only when the 
infection is mild or when the vaccine is given very early in the disease. 
In a severe, acute, general infection there is danger that the vaccine may 
aggravate the disease and not be followed by a favorable reaction. In these 
cases the tissues under the stimulation of the general bacterial invasion 
have already furnished the "high tide" of opsonins for the individual case 
and cannot further be stimulated to produce an increased quantity of these 
curative agents. The definite field of vaccine therapy has not as yet been 
determined, but there is no doubt that it exercises a curative influence in 
a group of cases which do not yield readily to other methods of treatment. 

Localized staphylococcic infections, especially those due to the staphy- 
lococcus pyogenes aureus, such as occur in furunculosis, pustular acne, 
sycosis, cystitis, carbuncle, and osteomyelitis, may be favorably influenced, 



58 THERAPEUTICS OF INFANCY AND CHILDHOOD 

and recovery accelerated by the use of the staphylococcus vaccines. While 
the above named conditions are very commonly due to staphylococcic in- 
fection, it is advisable to determine this fact by bacteriologic examination 
before using the vaccine. Especially good results have been obtained by 
this method in the treatment of chronic furunculosis. In the treatment of 
pustular acne with infiltration a combination vaccine containing both dead 
staphylococci and dead acne bacilli has been used with advantage. 

Koch's tuberculin has been successfully used as a vaccine in the treat- 
ment of tuberculosis, but it is of little value in the treatment of this disease 
during the first year of life. Localized non-febrile forms of chronic tuber- 
culosis (not meningeal), in children over two or three years of age, may 
be greatly benefited by this treatment, provided it is carried out as recom- 
mended by Trudeau. One should begin with very minute doses, .001 mg., 
and increase very gradually. The dose should be graduated so as to pro- 
duce a very slight clinical reaction. A second dose should not be given 
for some days after all effects of the previous reaction have passed away. 
This treatment should be continued only in those cases that continue to 
improve. It should not be hastened, as it requires many months to get 
results. The tuberculin treatment may hasten the cure of cases which by 
reason of outdoor life and proper food have begun to improve, and have 
thereby indicated that the opsonic content of their blood may be increased 
hy vaccine treatment. 

Gonococcus vaccine is of little value in the treatment of acute gonor- 
rhea except perhaps in the gonococcic vulvovaginitis of young infants, but 
in chronic cases, both in children and adults, the published reports indicate 
that it may shorten the course of this disease. The most important field 
for the gonococcic vaccine is found in the complications which are due to 
the action of this organism in other parts of the body. In subacute and 
chronic gonorrheal arthritis, and in chronic suppurative processes pro- 
duced by gonococci in any part of the body, the proper surgical treatment 
of these conditons will much more readily bring about a cure when com- 
bined with the use of the gonococcus vaccine. 

Streptococcus vaccine is, as a rule, not indicated in acute general strep- 
tococcic infections, but in all localized streptococcic infections, especially if 
they be subacute or chronic, this vaccine may be of value in facilitating a 
cure. Such localized streptococcic infections occur most commonly in 
association with, or as sequels of, influenza, epidemic grippe, tonsillitis, 
scarlet fever, tuberculosis and other acute infectious diseases. The ordi- 
nary sites of localized streptococcic infection are lymphatic glands, the 
serous cavities, the accessory sinuses of the nose and the subcutaneous tis- 
sues. In properly selected cases of this character the streptococcus vaccine 
may be of value. In the treatment of streptococcic infections autogenous 
vaccines are much to be preferred, because of the great variety of strains 
of this organism. 

Pneumococcus vaccine is of little or no value in the treatment of gen- 
eral pneumococcic infections or of pneumococcic pneumonia during the 



OTHER METHODS OF TREATMENT 59 

acute stage of the disease. It may be of value, however, in chronic forms 
of pneumococcic pneumonia in which there is delayed resolution; in sub- 
acute or chronic pneumococcic empyema, and in all localized pneumococcic 
infections, such as may occur in the joints, the internal ear, accessory 
sinuses of the nose and the urinary bladder. 

Typhoid vaccine has been successfully used as a prophylactic measure 
against typhoid fever; its value, however, in the treatment of the disease 
itself has not been demonstrated. The vaccine treatment of erysipelas, 
scarlet fever and other acute infectious diseases has not as yet been followed 
by sufficient success to demonstrate its value during the acute stages of 
these diseases. 

Coli vaccine is a valuable remedy in infection of the urinary tract due 
to this organism. It may also be given with some hope of success in 
colicystitis and catarrhal jaundice. 

Antiserums. — It has been a well-known fact for many years that most 
of the acute infectious diseases are self-limited, run a more or less definite 
course, and are cured by the development in the body of the animal of 
antidotal substances acting on or destroying either the bacteria or their 
poisonous products, and this process by which nature effects a cure of 
these diseases is followed by a period of permanent or temporary immunity 
from the specific bacterial disease from which the animal was suffering.' 
It seemed more than probable that if antiserums containing these antidotal 
substances could be artificially manufactured by immunizing horses or 
other animals by the injection into their blood or other tissues of certain 
>acteria and their poisonous products, these antiserums would act specific- 
ally in assisting nature in terminating or curing the specific infection 
caused by the microorganism which was used to produce the antiserum. 
A vast amount of experimental work in recent years has been directed along 
these lines with the result that certain antiserums have been produced which 
act specifically in the destruction of the parasite and its poisons without 
producing any injurious action on the body cells. The discovery of these 
antiserums furnishes the most notable therapeutic advance in the history 
of medicine. 

The development of antiserums for the cure of bacterial diseases is 
but yet in its infancy and many of the problems connected with their manu- 
facture are yet to be solved. Nevertheless, the achievements in this field 
of experimental medicine are nothing short of marvelous, and the future 
promises that achievements in this field of therapeutic research will be 
even more brilliant than the results which have been already obtained. At 
the present time it appears that there are at least two distinct classes of 
antiserums. 

The first is represented by the diphtheria and tetanus antitoxins. In 
these diseases the bacteria acting within a localized area of infection 
excrete soluble poisons which are distributed through the circulating media 
of the animal to all parts of the body, producing a dangerous and fre- 
quently a fatal toxaemia. The antiserums which are produced for the 



60 THEKAPEUTICS OF INFANCY AND CHILDHOOD 

cure of these diseases are essentially antitoxins which combine with and 
neutralize or destroy the poisonous effect of toxins, thus giving nature 
an opportunity to furnish such antibodies as are necessary to effectually 
terminate the disease. The brilliant results which have followed the treat- 
ment of diphtheria by antitoxin are fully discussed in the chapter on 
Diphtheria. 

The second class of antiserums is represented by the antimeningitis 
serum, the use of which has been followed by such brilliant results in the 
treatment of meningococcus meningitis. This serum is an antiendotoxic 
serum and is bacteriolytic rather than antitoxic. It acts primarily by de- 
stroying the meningococcus itself and secondarily by neutralizing the 
action of the toxins set free by the destruction of this microorganism. The 
toxins of the meningococcus, unlike those of the diphtheria bacillus, re- 
main united with the microorganisms which have produced them, and are 
not therefore thrown into the body media, producing a general toxemia. 
The antimeningitis serum depends for its bacteriolytic action upon the 
opsonins which it contains. These opsonins prepare the meningococcus 
for ingestion and destruction by the leukocytes. The brilliant results 
which have been obtained by this serum are given in detail under the 
treatment of Meningococcus Meningitis. 

Twenty years ago I wrote as follows: 1 "In imitating nature experi- 
mental clinical medicme has a promising field here opened for original 
work. In the cure and prevention of disease the experimenter may use 
one of two substances. 

1. The chemical substances produced by the body cells. 

2. The chemical substances produced by bacteria. 

Let us first note what results we may expect from the use of chemical 
substances produced by the body cells in curing disease. 

(a) By injecting these substances in sufficient quantity into the body 
of a healthy animal we would expect to confer complete temporary im- 
munity to the particular bacterium that induced their formation. But 
this immunity would gradually disappear with the excretion of the cause 
on which it depended. 

(b) By injecting these substances in sufficient quantities into the body 
of an animal sick of the disease we would expect it to act as a true specific 
in the cure of the disease. 

If, therefore, we could obtain the various chemical substances with 
which nature cures the self-limited diseases and with which she confers 
a temporary immunity against them we would have the means not only 
of curing but of preventing these diseases. 

Let us now note what beneficial results may be expected from the in- 
troduction of the products of bacteria. Whatever action these may have 
must depend upon their power of exciting the body cells to the production 
of substances that either destroy bacteria or neutralize their products and 

1 "Mechanism of Immunity," Philadelphia Medical News, April 23, 1892. 



OTHER METHODS OF TREATMENT 61 

thus terminate the disease and confer immunity. The disease is here 
terminated and immunity conferred not by the products of the bacteria, 
but by the products of the cells in the same manner as when the cellular 
instead of the bacterial products are introduced. "The only difference is 
that in the first instance the cellular products are formed in the body of 
one animal and introduced as a curative or prophylactic agent into the 
body of another animal and in the second instance the cellular products 
are formed in the body of the animal for the purpose of conferring immun- 
ity, * * * or terminating a self-limited disease." 

In the paper from which the above quotation is made I clearly outlined 
the possibilities and probabilities of the vaccine and antiserum treatment 
of bacterial diseases. 



SECTION II 
THE NEW-BORN 

CHAPTEE Y 

THE CAEE OF PREMATURE INFANTS 

Physical Peculiarities of the Prematurely Born. — Infants born prema- 
turely differ from full-term infants in the comparative lack of functional 
development of many of their most important organs. By reason of this 
lack of development they are to a greater or less degree, depending upon 
the stage of prematurity, unfitted to live under the ordinary conditions of 
home and hospital life. The most important and the most serious defect 
of the premature infant is the lack of development of its nervous system, 
and especially the undeveloped state of its heat-regulating apparatus. Its 
thermogenic centers are so poorly developed that it is unable to produce 
the requisite amount of heat to maintain a normal body temperature. The 
body temperature of the unborn infant is that of its mother, but this heat 
has been largely furnished by the surroundings of the infant and is not- 
due to the activity of its own heat-producing centers. At birth it is ushered 
into a room temperature between 70° and 80° F., and its body tem- 
perature rapidly falls and may within a few hours be as low as 85° F. 
The deficiency, however, of its heat-producing centers, which makes it de- 
pendent upon external heat for the maintenance of a normal body tempera- 
ture, is not the only defect in its heat-regulating mechanism. The prime 
defect in the nervous system of the premature infant is the almost com- 
plete lack of development of its inhibitory functions, and this lack of inhibi- 
tion is especially important in its influence, or rather lack of influence, on 
the heat-dissipating mechanism. This part of the heat-regulating ap- 
paratus is under so little control from higher nerve centers that the body 
heat of these infants is very rapidly dissipated when they are transferred 
from an intrauterine temperature of 99° F. to a room temperature of 
70° F. The therm oinhibitory centers of these infants also exert but little 
or no control over the thermogenic centers and as a result of this malad- 
justment of the heat-regulating mechanism it is very difficult to maintain 
a normal body temperature in these infants. Artificial heat when applied 
with the purpose of supplying the deficiency in body heat may produce 

62 



PECULIARITIES OF THE PREMATURELY BORN" 



63 



dangerously high temperatures. I have seen the rectal temperature of a 
premature infant raised to 109° F. by a careless application of artificial 
heat, and in the same infant when the artificial heat was removed I have 
seen the temperature drop, within a few hours, to 93° F. The lack of de- 
velopment and instability of the heat-regulating mechanism of the prema- 
ture infant predispose these infants to dangerously high and low tempera- 
tures from insignificant causes. Artificial heat, which is necessary to main- 



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-Temperature Curve Showing Influence of Artificial Heat on Prema- 
ture Infant. 



tain a normal body temperature in these infants, should be applied under 
the most careful supervision. 

The respiratory centers are also very imperfectly developed. Many of 
these infants are more or less asphyxiated at birth and in all of them the 
respiratory movements are feeble and shallow. The respiratory centers in 
these cases do not respond so energetically and satisfactorily to external 
reflex stimuli as they do in the full term infant. 

The higher nerve centers are also imperfectly developed, so that these 
infants are somnolent, quiet and motionless a great portion of the time; 
6 



64 THE CAEE OF PREMATURE INFANTS 

when aroused from their stupid condition they whine faintly, instead of 
uttering the lusty cry of the normal infant. 

The reflex centers in the spinal cord, as well as those of the brain and 
medulla, are comparatively undeveloped. As a result of this there are com- 
parative lack of muscular movement in the arms and legs, deficient tone 
in the muscles of the extremities, constipation or insufficient evacuation of 
the bowels. 

The second most important defect in development is to be found in the 
digestive tract. The digestive organs of premature infants are, as com- 
pared with those of the normal child, to a greater or less degree physiologi- 
cally incompetent. The degree of this physiological incompetency will 
depend upon the stage of prematurity. Infants born between the sixth and 
seventh month may manifest little inclination to suck ; this reflex function 
is but feebly developed, and swallowing may be accomplished with difficulty. 
In infants born nearer full term there is usually no disturbance of the 
reflex acts of sucking and swallowing, but the digestive ferments are dimin- 
ished in quantity and the digestive capacity is therefore markedly di- 
minished. The degree of functional development of the gastrointestinal 
organs of the premature infant is of the very greatest importance from the 
standpoint of prognosis, since its life as well as its development depends 
upon its capacity to digest and assimilate sufficient food, not only to furnish 
body heat, but to supply nutrition for its growth and development. Among 
the prominent and discouraging symptoms, therefore, are those which arise 
from gastrointestinal indigestion. The meconium is passed for five or six 
days, but after this normal milk stools should begin to appear. If, however, 
the infant fails in its digestive capacity and the discharges indicate a 
gastroenteric indigestion, the prognosis becomes very grave indeed. 

The susceptibility to infection is increased with the degree of imma- 
turity of these infants and this susceptibility depends not only upon the 
lack of resistance to pathogenic microorganisms due to a lack of develop- 
ment of the defensive mechanisms by which normal infants offer more or 
less resistance to invading bacteria, but also to the ease with which these 
microorganisms find an entrance through the imperfectly developed skin 
and mucous membranes. Alexins and other antibodies are markedly 
deficient in the premature infant, and for this reason it much more readily 
succumbs to infections which find entrance through the umbilical wound, 
the skin, mouth, gastrointestinal canal, and, perhaps of even more impor- 
tance, through the respiratory passages. Premature infants are especially 
predisposed to all forms of general sepsis, to bronchopneumonia, bronchitis, 
gastrointestinal disorders and hemorrhagic diseases associated with serious 
forms of malnutrition. 

Very commonly prematurity is produced by some severe constitutional 
disease in the mother, such as syphilis or tuberculosis. Infants of this 
type usually suffer from a severe form of hereditary syphilis, or from 
pronounced malnutritions, which are quite independent of the retardation 
in development which characterizes uncomplicated prematurity. Infants 



TREATMENT 65 

who are not only premature but are congenitally weak and malnourished 
as a result of hereditary disease have much less chance for attaining normal 
development than has the infant who suffers simply from uncomplicated 
prematurity. 

In addition to the symptoms which have been dwelt upon above, pre- 
mature infants are markedly underweight, and their birth weight is of 
great importance from the standpoint of prognosis. Viable premature in- 
fants may vary in weight from two and one-half to six pounds. Death 
almost always occurs if the body weight is less than two and one-half 
pounds. With the increasing birth weight of the infant the prognosis 
becomes more favorable. The skin of the premature infant is commonly 
slightly jaundiced. Its extremities, and in fact the whole surface of its 
body, feel cool to the touch, and with the feeble and shallow respiratory 
movements we may have cyanosis, dyspnea, or asphyxia. 

Prognosis. — The prognosis depends largely upon the rectal tempera- 
ture and the possibility of producing and maintaining a comparatively 
normal body temperature under the influence of artificial heat. It depends 
also, as previously stated, upon the weight of the infant and upon its 
ability to take and assimilate sufficient food to supply its body wants. 
Under favorable conditions in private families, where the infant can be 
at once properly treated without first allowing it to become chilled and 
to suffer from a low body temperature for a number of hours, the prognosis 
is good. The majority of cases born after the seventh month and weighing 
more than three pounds develop into normal, healthy infants. Premature 
infants who are neglected for the first twelve hours of their lives, and who 
perhaps during this time are transferred from one institution to another, 
have greatly diminished chances for living. The prognosis in breast-fed 
premature infants is vastly better than in those which are fed upon arti- 
ficial food. When syphilis and other forms of congenital debility are added 
to the prematurity, the prognosis is for the most part unfavorable. 

Treatment. — As premature babies very commonly suffer from asphyxia, 
the earliest treatment of these cases consists in clearing the throat of mucus 
and other fluids and establishing normal respiratory movements by the 
resuscitating measures outlined under Asphyxia. Following the establish- 
ment of normal respiration, the infant's body is to be cleansed with oil and 
absorbent cotton and its eyes carefully washed with a saturated solution of 
boracic acid. It is then to be carefully wrapped in absorbent cotton so 
that its whole body, except the face, hands and buttocks, is wholly covered ; 
the absorbent cotton should be held in position by gauze bandages. The 
object of thus covering the infant with a thick layer of absorbent cotton 
immediately after birth is to prevent the sharp fall in body temperature 
which may occur at this time. The buttocks are to be protected by sep- 
arate pieces of cotton so adjusted as to catch the excreta without fouling 
the entire dressing. The cotton dressing above described is to be changed 
once in twenty-four hours in a warm room with the infant before an open 
fire. When the dressing is removed, before another similar dressing is 



66 THE CARE OF PREMATURE INFANTS 

applied, the infant's body is to be cleansed with cotton and warm olive oil. 
This form of dressing should continue to take the place of clothing for 
from one to three weeks, depending upon the stage of immaturity of the 
infant. As soon as the heat-regulating apparatus of the infant commences 
to assume normal control of the body temperature, these wrappings may 
be gradually changed for the clothing ordinarily worn by newly-born in- 
fants. The skin, buttocks and mucous membranes of the nose and mouth 
should be kept clean and free from irritation. The position of the infant 
should be frequently changed so that no portion of the skin will be sub- 
jected to body pressure for any great length of time. This is important 
since these infants will lie for an indefinite length of time in one position, 
making no movement and uttering no cry. 

Incubator. — The most important part of the treatment is that of 
maintaining an approximately normal and even temperature of the infant's 
body by artificial means, without causing it to breathe an overheated impure 
air. This problem is very difficult of solution; to solve it incubators were 
introduced and they are now in general use and recommended by all 
authorities. Only incubators of the most approved type should be used 
and they require careful supervision by competent attendants night and 
day. The heat-regulating apparatus of the best of incubators may at times 
get out of order, and as a result the infant may be exposed to great heat or 
cold, and such an accident may be fatal to the incubator infant. 

The experience of pediatricians has been that an incubator temperature 
above 85° F. is prejudicial to the welfare of infants and that they thrive 
best at a temperature of 80° F. With this amount of artificial heat added 
to that which the infant can manufacture the rectal temperature of the 
incubator infant should be between 93° and 97° F. Normal temperatures 
are not to be expected during the first or second weeks of treatment, but 
if the infant's temperature remains constantly below 90° F. the prognosis 
is very unfavorable. It is advisable, especially in institutional work, that 
the air supplying the incubator should come from the outside, so as to 
have it as pure and as free from microbic contamination as possible. Incu- 
bators, when properly constructed and carefully watched throughout the 
whole of the twenty-four hours, have given good results both in institutional 
and private practice. 

Padded Basket. — My own experience is, in accord with that of many 
other pediatricians, that the cotton-padded basket is more easily managed 
and gives as good results as the incubator, especially in private practice. 
In carrying out this treatment the premature infant, after being cotton- 
wrapped as above described, is placed in a basket, the inside of which has 
been previously heavily padded with cotton and covered with gauze, and 
the space within the basket when thus padded should be at least twice the 
length of the infant, so that warm water bottles or electric heaters can be so 
placed as to apply artificial heat to the child's body without coming in 
direct contact with it. The infant thus covered with warm blankets and 
its bed warmed by artificial heat is placed in a large, quiet, warm, well- 



TBEATMENT 67 

ventilated room; the temperature of this room should be about 80° F. 
If the room has an open fireplace this should be utilized during the cold 
months to assist in warming and ventilating the room, and at least one 
window in the room should be partially open to let in a stream of pure 
fresh air. The infant's basket-bed should be placed in the warmest part 
of the room, away from the draught of windows and doors. All persons, 
except the nurse and mother, should be excluded from the room, and above 
all contagions of every kind are to be carefully avoided. All individuals 
suffering from slight coryzas, colds in the head, or any other catarrhal con- 
ditions of the respiratory passages should be excluded from the room. 
These infants are not only very susceptible to contagions of all kinds, but 
when once the contagion is started they offer little or no resistance to it. 




Fig. 12. — Padded Basket for Treatment of Premature Infants. 

A simple rhinitis or an ordinary cold may prove a fatal complication in 
that it may lead to bronchitis or bronchopneumonia. 

The basket, when all the above details of treatment can be carefully 
carried out, is safer and, as I believe, gives as good results as the incubator. 
The basket may also be used in institutional work instead of the incubator 
if the infant can be isolated as above described. This basket treatment, 
however, in the crowded wards of a city hospital is very unsatisfactory; 
the incubator with its outside ventilation is preferable under such con- 
ditions. 

Feeding of Premature Infants. — Breast Feeding. — Feeding is of 
almost as much importance as the treatment above given for maintaining 
the body temperature and furnishing fresh air. Every premature infant 
should, if possible, be fed upon breast milk, otherwise its chances for re- 
covery are very greatly diminished. Within the first twenty-four hours the 
infant requires no food; during this time a little water slightly sweetened 
with milk sugar may be given; this gives the physician an opportunity 
to find a wet nurse. The mothers of premature infants are not prepared 
to furnish breast milk ; the milk secretion is not established in most cases 



68 



THE CARE OF PREMATURE INFANTS 



until a week or ten days have elapsed, and then in many instances this 
result is brought about by the frequent use of a breast pump or by the 
nursing of another healthy infant. Furthermore, even when the milk 
secretion of the mother commences to be established it contains for a num- 
ber of days so much colostrum that it is not a suitable food for a premature 
infant. A wet nurse should therefore be employed for two or three weeks 
until the milk secretion of the mother is fully established, and during this 
time the infant of the wet nurse may be used to develop the milk secretion 
of the mother and at the same time to keep up the normal supply of breast 
milk in the wet nurse. 

Premature infants are not, as a rule, able to suck ; the breast milk must 
therefore be drawn from the breasts with a breast pump and fed to the 
infant by means of a pipette or some kind of infant feeder, 
such as that devised by Breck. If the child of the wet 
nurse is not allowed to nurse its own mother, the quantity 
of breast milk will quickly become deficient, but under the 
stimulating influence of sucking the quantity of milk given 
by the wet nurse will be quite sufficient to supply both in- 
fants. Later the breast milk of the mother may be sub- 
stituted for that of the wet nurse. 

Artificial Food. — In the event that it is absolutely im- 
possible to obtain suitable breast milk an artificial food 
formula must, of course, be resorted to. During the first 
three days it is advisable to give a 2 to 4 per cent, solu- 
tion of milk-sugar, and by the end of the third day closely 
skimmed milk may be added to the milk-sugar solution, 
one part of skimmed milk to six parts of a 4 per cent, 
milk-sugar solution. From day to day the quantity of 
skimmed milk may be increased until at the end of the 
week it is taking one part of skimmed milk to three parts 
of sugar solution. By this time the intestinal canal has 
been cleared of meconium, and normal intestinal discharges should indicate 
that the intestinal canal is in a condition to take a modified milk formula 
containing fat as well as sugar and protein. The infant may then be given 
0.5 per cent, fat, 0.3 per cent, protein and 4.00 per cent, sugar. As time 
goes on the fat and protein content of this food mixture is gradually in- 
creased, so that by the end of the third week the infant may be taking a 
1.00 per cent, fat, 0.75 per cent, protein and 5.00 per cent, sugar mixture. 
As the infant thrives the protein and fat percentages in this formula are 
to be slowly increased according to the rules outlined in the chapter on Ar- 
tificial Feeding. 

Quantity of Food. — As both the breast milk and the modified cow's 
milk are fed to these infants with some kind of a feeding tube, the quantity 
of food taken can be accurately measured. After the second or third day, 
when the feeding with breast milk is begun, the infant should have from 
four to seven ounces of milk in twenty-four hours, The quantity given 



Fig. 13. — Breck's 
Feeding Tube. 



ASPHYXIA NEONATORUM 69 

will depend upon the weight of the infant. The four ounces is suitable 
for an infant weighing between two and three pounds; the seven ounces 
for an infant between five and six pounds. Day by day as the infant grows 
older the quantity of breast milk is increased, so that by the end of the 
second week the infant which began with four ounces will be taking four- 
teen or fifteen ounces in twenty-four hours, and the infant which began 
with seven ounces will be taking seventeen or eighteen ounces in twenty- 
four hours. The same quantities of modified cow's milk may be given to 
those infants who are unfortunate enough to be deprived of breast milk. 
The interval between the feedings should, in the beginning, be one and one- 
half hours. At the end of two weeks this interval should be prolonged 
to two hours. This will make the individual feedings vary from one-half an 
ounce in the very small premature infant to one ounce or one and one-half 
ounces in the large premature infant. As soon as the infant is strong 
enough it should be put to the breast. In many cases it may be possible 
to obtain a small but insufficient quantity of breast milk. In such cases 
mixed feeding should be resorted to, and this mixed feeding should be 
followed out according to the method carefully detailed in the paragraph 
on Mixed Feeding in the section on Artificial Feeding of Infants. All of 
the breast milk that can be obtained should be given at each feeding and 
this is to be supplemented by a modified milk formula given at the same 
time and in sufficient quantity to make up the deficiency. 

Premature infants which thrive properly should develop into normal, 
sturdy children, leaving no trace of weakness as a result of their prema- 
turity. In the beginning these children, like normal infants, lose slightly 
in weight, but after a week or ten days they should have regained their 
birth weight, and thereafter should continue to slowly increase in weight. 
In the beginning a gain of two to three ounces per week is considered satis- 
factor} T , but after five or six weeks, when they are strong enough to nurse 
the breast and to take larger quantities of milk, their gain in weight should 
become more rapid. 



CHAPTER VI 
DISEASES OF THE NEW-BORN 

ASPHYXIA NEONATORUM 

Etiology. — Asphyxia is due to deficient oxygenation of the blood and 
the resulting symptoms are in part produced by the poisonous action on 
the nerve centers of carbon dioxide. As the infant during intrauterine life 
is dependent upon the placenta for its supply of oxygenated blood it may 
be asphyxiated by anything that interferes with the placental circulation. 
The most common cause of this condition is pressure or twisting of the 
umbilical cord during labor. The cord may be prolapsed or it may be 



70 DISEASES OF THE NEW-BORN 

wrapped around the neck or some other portion of the infant's body in 
such a manner that, during delivery, especially if it be prolonged, the cir- 
culation between the placenta and the infant is cut off and asphyxiation 
results. This is more liable to occur during breech presentations and dur- 
ing protracted labor following the premature discharge of the liquor amnii ; 
in these conditions the cord is so firmly pressed against the body of the 
child by the strong uterine contractions that circulation through it is im- 
peded or entirely obstructed. Asphyxia may also be produced by cerebral 
hemorrhage, by defective development, by the premature detachment of 
the placenta and by the death or serious illness of the mother during labor. 
If the child is asphyxiated before labor begins it is stillborn and the extent 
of the maceration of its skin and the general appearance of the dead fetus 
may give some idea of the length of time it has been dead. 

Asphyxiation may also occur after birth in premature and malnourished 
infants as a result of defective development of the muscular and nervous 
mechanisms which preside over the respiratory movements. In this type 
the infant, which has been kept alive by the placental circulation during 
intrauterine life, has not sufficient vitality to establish normal respiratory 
movements after birth. Fortunately these hopeless cases are very uncom- 
mon. Criminal neglect of the infant just after birth may allow it to lie 
face downward in the blood and mucus which has been discharged during 
labor, and in this manner it may become asphyxiated. 

Symptomatology.' — In those cases where asphyxia occurs during labor 
the carbon dioxide poisoning and the air hunger bring about premature 
inspiratory efforts, and, as a result, mucus and other secretions may be 
drawn into the respiratory passages and by strangulation increase the ex- 
isting asphyxia. 

The symptom groups which characterize the mild and severe types of 
asphyxia are somewhat distinct. The mild form is spoken of as asphyxia 
livida. In this condition the skin is blue and the mucous membranes are a 
dark purple color. The infant lies more or less motionless, but is not limp 
or apparently lifeless ; its muscles are not relaxed, its reflexes are commonly 
present, its pupils are not dilated and the action of its heart can be dis- 
tinctly heard and commonly felt by placing the finger over the location of 
the apex beat. The infant, however, does not cry, and its respiratory 
movements are irregular, shallow or gasping. 

In the severe form known as asphyxia pallida (Runge) the child at 
first sight is apparently dead. It has a pale, pasty, cadaverous look about 
its face; its lips are dark blue, its body and extremities are cold and there 
is a general lack of tone or flaccid condition of all the muscles. As the 
child is lifted its body seems limp and lifeless, reflexes are absent, pupils 
are dilated, there are no efforts at respiratory movements, and the only evi- 
dence of life is to be found in the feeble heart beat, which can be heard 
but not felt. In some of these cases a few gasping efforts at inspiration 
may be made, but the mucus which has accumulated in the throat and 
upper respiratory passages prevents the entrance of air into the lungs. It 






ASPHYXIA NEONATORUM 71 

is evident from the above description that there is no clear line of demarca- 
tion between asphyxia livida and asphyxia pallida. The livid and pale 
forms of this disease represent but different grades of severity. One may 
meet cases of asphyxia so mild that slight cyanosis and irregularity in 
breathing are the only symptoms, and again the case may be so severe that 
all efforts at resuscitation fail, and the clinical picture of asphyxia pallida 
is aggravated until the cessation of the heart beat announces the death 
of the infant. Between these two extremes we may have every grade of 
severity. 

Diagnosis. — It is important to remember that cerebral hemorrhage oc- 
curring during labor may produce a symptom group closely resembling 
asphyxia. Perhaps it might be more accurate to say that asphyxia is a 
part of the symptom group in many of the cases of cerebral hemorrhage. 
It is important, therefore, in all cases of asphyxia neonatorum to withhold 
the ultimate prognosis until it can be determined whether or not there is a 
coexisting cerebral hemorrhage; this can in most instances only be decided 
by the subsequent history. In asphyxia, when respiration has been estab- 
lished, the improvement is very marked, but while the child is weak there 
may be a tendency to a slight return of the asphyxia in the first twenty- 
four or thirty-six hours, yet under careful nursing satisfactory convalescence 
is soon established. This is not true of cerebral hemorrhage severe enough 
to produce asphyxia. In these cases we are likely to have localized or even 
slight general convulsions recurring over a number of days, and the infant 
during this time remains in a dull and stupid condition. Thereafter con- 
valescence, as compared with that of uncomplicated asphyxia, is very slow. 
It should be remembered that in these cases of cerebral hemorrhage one 
may not have for weeks and months the characteristic symptoms of spastic 
palsy, so that the absence of this palsy in the newly-born infant suffering 
from asphyxia does not exclude cerebral hemorrhage. 

Prognosis. — The prognosis depends largely upon the character of the 
asphyxia and the treatment instituted. If well marked it is always a 
grave symptom. In general terms, however, one may say that the prognosis 
in asphyxia livida is good if the cases are properly treated, and that the 
prognosis in asphyxia pallida, while bad, is not always fatal. In cases due 
to cerebral hemorrhage the prognosis as to life is unfortunately good. I say 
unfortunately, since nearly all of these cases are hopelessly defective in 
their mental development (Jacobi). 

Prophylaxis. — The preventive treatment of asphyxia is largely obstet- 
rical. Breech presentations and tedious labors, especially in cases where the 
liquor amnii has been discharged prematurely, should be terminated as 
rapidly as possible. In cases of this kind, where asphyxia may be expected 
to result, the infant immediately after birth should receive prompt and 
skilful attention. The mucus and other foreign matter in its throat should 
be quickly wiped out with a moist cloth covering the finger, and it should 
be held up by the legs, head downward, and gently shaken, as this procedure 
facilitates the removal of the inspired fluids and stimulates by congestion 



72 



DISEASES OF THE NEW-BOEN 



the respiratory centers. Slapping the body of the infant with a cool rag or 
dipping it alternately into a bucket of warm and cool water may reflexly 
stimulate respiratory movements. This may be done three or four times in 
a minute until the infant begins to cry and more or less normal respiratory 
movements are established. This treatment when promptly administered 
will prevent many cases of asphyxia. 

Treatment.— When the infant is born asphyxiated the object first sought 
is to clear the respiratory passages of inspired mucus and liquor amnii. 
This is accomplished, as above stated, by holding the infant head downward, 
shaking it, and at the same time, with a gauze-wrapped finger, removing 
the mucus and other fluids from the throat. If evi- 
dences of strangulation still exist a small, soft, rub- 
ber catheter, cut off at the end, should be introduced 
into the opening of the larynx and the fluids re- 
moved by suction or aspira- 
tion. In emergency cases of 
this kind there is no time for 
the operator to provide him- 
self with an instrument espe- 
cially devised for this pur- 
pose, and valuable time 
should not be lost in prepar- 
ing an instrument which will 
protect the mouth of the op- 
erator from these inspired 
fluids which are being drawn 
from the respiratory passages 
of the infant. These manip- 
ulations having been made, 
as quickly as possible, to 
clear the respiratory pas- 
sages of fluid, the child is 
placed upon a bed face up- 
ward and a piece of gauze 
thrown over its mouth; the physician then, after closing the nose of 
the child with one hand and making firm pressure over the stomach with 
the other, places his lips to that of the infant and blows air from his own 
lungs into those of the infant, and as he thus inflates its lungs he can see 
the movements of the chest walls; the air is expelled from the lungs by 
pressing upon the chest wall. This method of lung inflation may be re- 
peated every few minutes until the infant begins to cry or makes efforts 
at. normal respiratory movements; artificial respiration should then be re- 
sorted to. 

Artificial Respiration. — Schultze's method, which is recommended 
by all writers upon this subject, is the most valuable and is described as 
follows: The physician, standing, grasps the infant with both hands, his 




Fig. 14. 



-Schultze's Method of Artificial Res- 
piration. (After Edgar.) 






CONGENITAL ATELECTASIS 73 

palms resting upon the child's shoulders, his thumbs extending over the 
anterior surface of the chest near the axilla, his ringers spreading out over 
the scapula?, and the infant's head, resting between his arms, is supported 
by his wrists. The infant, firmly grasped in this manner, is swung upward 
above the operator's head; in doing this its body is bent forward, its ab- 
dominal viscera pressed upward against the diaphragm and expiration is 
thereby accomplished. The child's body is now swung backward in the same 
circle until its body hangs downward with its spine bent slightly backward ; 
with this movement the diaphragm sinks and inspiration is accomplished. 
This operation is repeated some ten or fifteen times a minute until normal 
respiratory movements begin to be established. In employing this method 
unnecessary chilling of the infant's body is to be avoided as much as 
possible. 

Other methods of artificial respiration are recommended. A modifica- 
tion of the Schultze method described by Dew consists in holding the 
infant back downward in such a way that its body may be bent in much 
the same manner as in the swinging movements above described. The body 
of the child is alternately flexed and extended so as to push the diaphragm 
upward and pull it downward, thus producing expiration and inspiration. 
These manipulations may be made, as Ela recommends, while the infant is 
in a warm bath, temperature 100° to 105° F. The combination of warm 
bath and artificial respiration is especially to be recommended in asphyxia 
pallida. Artificial respiration may also be carried on in young infants as it 
is in older children by placing the child, face upward, in,a prone position 
with its shoulders slightly elevated above the rest of its body, and then 
gradually lifting the arms high above the head in a line with the body and 
again bringing them down, at the same time making compression down- 
ward and inward against the whole anterior and lateral surfaces of the 
chest wall. 

Following its resuscitation and the establishment of normal respiration 
the infant must be carefully watched for twenty-four or thirty-six hours, 
and in the event that signs of asphyxia begin to recur it must again be 
subjected to one or the other methods above detailed for bringing about 
normal breathing. The inhalation of oxygen is sometimes of benefit in these 
recurrent cases. Strychnia, 1/400 or 1/500 of a grain, given hypoder- 
mically, has also been recommended in these cases. As some of the severe 
cases are unable to nurse for three or four days, it may be necessary to feed 
them with a medicine dropper and to give them occasionally a few drops 
of whiskey well diluted. 

CONGENITAL ATELECTASIS 

The lungs of the infant at birth are collapsed, contain no air, or. in 
other words, are in a state of congenital atelectasis. With the first inspira- 
tory efforts the lung commences to expand. This is a gradual process and a 
number of days elapse before the entire lung is inflated. If any portion 



74 DISEASES OF THE NEW-BORN 

of the lung fails to expand, it remains in its fetal condition of collapse or 
congenital atelectasis. It is, moreover, evident that the extent of this con- 
dition may vary greatly from a slight and scattered atelectasis, which re- 
sults simply from delay in the inflation of the lung, to an atelectasis so 
extensive that the whole of one lung may be involved or such extensive 
regions of both lungs that life under these conditions is impossible, and 
the infant dies from asphyxia. 

Etiology. — All of the causes which predispose to asphyxia neonatorum 
are also important factors in the production of atelectasis. It occurs in 
premature infants, in feeble, malnourished infants, in those suffering from 
congenital syphilis, and in infants suffering from cerebral hemorrhages and 
other birth injuries. Inspired fluids, such as mucus and liquor amnii, which 
may be sucked into the bronchial tree with the first inspiratory efforts, may 
obstruct the smaller bronchi and prevent the inflation of the portions of the 
lungs to which they carry air. Obstructive atelectasis may also occur after 
normal respiratory movements have apparently been established. In such 
cases portions of the lung which have been inflated again return to their 
atelectatic condition, thus producing a form of acquired atelectasis. These 
cases of acquired atelectasis occurring in the new-born are, as a rule, due 
to the plugging of the bronchial tubes with mucus or with inflammatory 
products. In this chapter, the acquired atelectasis which occurs in older 
infants as the result of bronchitis, bronchopneumonia, pleurisy and rickets, 
will not be considered. 

Symptomatology. — The symptoms are commonly associated with, and 
practically cannot be separated from, those of asphyxia neonatorum, or per- 
haps one might more clearly express this relationship by saying that a 
greater or less degree of asphyxia is a constant symptom of atelectasis. 
When the atelectasis is so slight as not to produce any evidences of asphyxia 
whatever, then it cannot, as a rule, be discovered by other physical signs 
and symptoms. The respiratory movements in atelectasis are defective. 
They are usually irregular and shallow. Sometimes long pauses occur, fol- 
lowed by a gasping respiration, with the resumption for a time of irregular 
and superficial respirations. The more pronounced these symptoms the 
more aggravated the case. In the milder cases respiratory action is but 
slightly interfered with. In the most severe cases complete asphyxia oc- 
curs. 

These infants are, as a rule, feeble, somnolent and ominously quiet, not 
demanding, and usually not taking, sufficient nourishment. The tempera- 
ture is subnormal, the face pale and comparatively expressionless. On deep 
inspiration, which may be brought about by slapping the child with the 
hand, or applying cool water to its chest, one may hear, at the base of the 
lungs, crepitant or subcrepitant rales. Where the atelectasis is severe, and 
more marked on one side than on the other, lack of symmetry in the 
respiratory movements of the chest wall may be observed. In those cases 
which live for weeks without the disappearance of all the symptoms of 
atelectasis it is possible or even probable that an afebrile, insidious broncho- 






SEPTIC INFECTION IN THE NEW-BORN 75 

pneumonia may develop at any time. In such cases the physical signs of a 
bronchopneumonia are commingled with those of atelectasis. 

Treatment. — The somnolence and shallow, irregular breathing of these 
children are to be combated by much the same measures recommended for 
the treatment of mild cases of asphyxia. From six to eight times during 
every twenty-four hours these infants should be thoroughly aroused and 
made to take a number of deep inspirations by dipping them alternately 
into warm and cold baths, as recommended in asphyxia. In milder cases, 
or as improvement goes on, the same result may be accomplished by shaking 
and slapping the child and by wiping its face and chest with a cloth 
that has been dipped in cool water. As these infants commonly have a 
subnormal temperature it is necessary that they should be kept in a com- 
paratively warm room, and sometimes, in addition to this, artificial heat 
in the form of hot water bottles placed in the bed near the feet of the 
infant is necessary. The fulfillment of these conditions makes it almost 
impossible during the cold winter months to give them the amount of fresh 
air they require; the windows cannot be opened and they cannot be sub- 
jected to the fresh air treatment recommended in pneumonia; for this 
reason oxygen inhalations are of the very greatest importance. Perhaps 
most important of all is the feeding of these infants; they are, as a rule, 
too feeble and breathless to nurse milk from the breast, and yet breast 
milk is almost absolutely necessary to their proper nutrition. Feeding 
upon artificial food is not to be thought of unless it be absolutely impossible 
to obtain breast milk. Until the infant is able to nurse the breast milk 
should be drawn with a breast pump and fed with an ordinary medicine 
dropper. In such cases it is necessary, as a rule, to employ & wet nurse, or 
to secure the services of another infant to nurse the breast and develop 
the milk secretion of the mother. 



CHAPTER VII 
DISEASES OF THE NEW-BOEN (Continued) 

SEPTIC INFECTION IN THE NEW-BORN 

Etiology. — This is an infection produced by pus-forming organisms, 
such as the streptococcus pyogenes, staphylococcus pyogenes aureus and 
albus, colon bacillus, pneumococcus, bacillus pyocyaneous, and occasionally 
by other microorganisms, such as the gonococcus,. bacillus enteritidis and 
bacillus of Friedlander. When these microorganisms find their way into 
the blood and internal organs of the infant a condition of sepsis is nearly 
always produced. Localized lesions of the umbilicus, skin, vagina, eye. 
mouth, etc., may be produced by these microorganisms without a general 
sepsis supervening. These localized conditions, unless they be associated 
with a bacteremia or with inflammation of internal organs produced by the 



76 DISEASES OF THE NEW-BOKN 

same microorganisms, are not to be considered under the term sepsis as 
used in this chapter. 

Newly-born infants are very prone to septic infection. In the first 
place, because as compared with older infants and children the portals of 
entrance for septic organisms are more numerous and more open, and in 
the second place because at this age there is comparatively little natural 
resistance to these microorganisms when they have once found an entrance 
into the blood or other deeper tissues. This feeble resistance is perhaps 
closely associated with the undeveloped condition of lymphatic structures 
and with the comparative deficiency in the blood at this age of antibodies 
and other protective agents with which nature in older children and in 
adult life very successfully fights bacterial invasion. Breast-fed babies 
offer more resistance to septic infection than do those fed upon artificial 
food. This is perhaps because they derive from the milk of the mother the 
antibodies to which her partial immunity is due. Septic infection is more 
common and runs a more severe course in premature infants or those who 
are congenitally weak and in those suffering from profound malnutrition 
due to lack of proper food, hereditary disease or other causes. 

Portals of Entry. — Infection commonly occurs through the umbilicus. 
In a large percentage of the cases the portal of entry cannot be discovered, 
but there is little doubt that many of these are umbilical in origin. It is 
perhaps wise to assume umbilical infection in all doubtful cases, even in 
those in which the umbilicus appears normal. The thrombi which form 
in the ligated umbilical veins may easily become infected by the pyogenic 
organisms associated with the necrotic disintegration of the stump of the 
cord. Under such infection these thrombi break down into purulent ma- 
terial, phlebitis results and the septic matter in the umbilical vein finds its 
way into the general circulation. In this way a general septicemia is pro- 
duced, and emboli may be carried into almost any organ in the body, pro- 
ducing localized septic processes. The liver, lungs, intestinal canal and 
membranes of the brain may thus become infected. The liver, in fact, bears 
the brunt of the septic onslaught in all cases of septic infection originating 
at the umbilicus, as the blood from this region is carried through the liver 
into the general circulation. Septic infection may find entrance through 
abrasions, fissures or ulcerations of the skin or mucous membranes. It may 
be introduced into the mouth or nose by unclean fingers or dirty bath water. 
The lungs and intestinal canal may be portals of entrance for a general 
septic infection. In these cases it is believed that infected mucus and liquor 
amnii reach the lungs during the first inspiratory movements or enter the 
intestinal canal in the early efforts of deglutition. Septic infection may 
occur through the ear and much more rarely through the eye and genital 
tract. 

Source of the Infection.— The infection, as above noted, may have its 
origin in the sloughing of the stump of the umbilical cord, but it is be- 
lieved that in the great majority of the cases, even those which have their 
portal of entrance through the umbilicus, the infection comes from without 



SEPTIC INFECTION IN THE NEW-BOKN 77 

and the umbilical wound ia inoculated, in some way, with septic organisms 
other than those engaged in the normal necrotic process incident to the 
removal of the stump of the cord. This inoculation may occur not only to 
the umbilical wound, but to any of the other portals of entrance previously 
mentioned. The common sources of infection are the vaginal discharges of 
the mother, unclean hands of the nurse or physician, dirty clothing, con- 
taminated air or impure breast milk and dirty bath water. In short, infec- 
tion may result from any agent which carries septic microorganisms to the 
portals of entrance which happen to be open in the individual infant. 

Septic infection may also be transferred directly through the placental 
circulation to the unborn fetus by a septic mother. This method of trans- 
mission is comparatively rare and is of little etiological importance in the 
disease under discussion. A large number of other microorganisms, such 
as the tubercle, the typhoid, the cholera, and the influenza bacillus, and the 
specific contagion of measles, scarlet fever, pneumonia, and other acute 
infections, may occasionally be transferred from the mother through the 
placental circulation to the unborn infant, but infections such as these have 
been elsewhere considered and have no bearing on the disease under dis- 
cussion. 

Symptomatology. — The clinical syndromes presented by septic infections 
in the new-born vary greatly and the symptoms which announce the onset 
of this condition depend largely upon the portal through which the septic 
organisms have entered. In umbilical infection there is commonly a sharp 
elevation of temperature followed by a few days of septic fever and there- 
after the temperature may be normal or subnormal. Jaundice is a common 
and early symptom. The liver is generally enlarged and the umbilicus is 
usually inflamed and contains pus, which may be seen filling the umbilical 
depression, or may be caused to ooze out of the patulous umbilicus on 
pressure. It should be remembered^ however, that a normal umbilicus does 
not positively exclude umbilical infection. Suppuration may be going on 
in the thrombi filling the umbilical vein without external evidence of such 
condition. In this form of sepsis abdominal tenderness, distention and 
general peritonitis usually develop. 

Where the infection enters through the skin or mucous membrane there 
is, as a rule, some ulceration or abrasion which indicates the point of 
entrance of the poison. In such cases erysipelatous eruptions, pemphigus, 
pressure sores, deep ulcerations of the skin, furuncles, edema, sclerema, or 
gangrene may be observed. 

Where the infection enters through the mouth ulcerations of the tonsils 
or of the mucous membrane of the mouth or nose may be observed. In 
some instances the mucous membrane is fissured, dry, and patches of thrush 
or small aphthous ulcers may be scattered over it. 

Where the lungs are the portal of entrance there is associated with the 
general sepsis an early bronchitis, pneumonia, bronchopneumonia, pleuro- 
pneumonia, or empyema, so that the general sepsis is largely obscured by 
these local manifestations. 



78 DISEASES OF THE NEW-BOKN 

When the gastrointestinal canal is the portal of entrance the symptoms 
of general sepsis are largely obscured by the gastroenteric infection and 
acute enteritis, which are early manifestations. 

When the ear is the portal of entrance symptoms of meningeal irritation 
followed by meningitis and often by paralysis of the face or other muscles 
are early symptoms. 

Individual Symptoms. — As previously noted, the common portal of 
entrance is the umbilicus, and therefore the syndrome above noted as an- 
nouncing this disease when it comes from umbilical infection is far and 
away the most common mode of onset in septic infections of the new-born. 
This gives prominence to jaundice as a symptom of this disease. Jaundice, 
however, is not always present. In many cases, as the disease progresses, 
the face of the infant presents a gray and sickly pallor; in other cases a 
marked cyanosis is present. Purpura occurring as a fine petechial rash or 
as large dark-blue spots scattered over the body is also a common symptom 
of advanced sepsis. 

The fever is very irregular and misleading. For a few days following 
the onset it may be septic in character, reaching 104° or 105° F. at some 
time during the day, and falling below normal at another. In a few days, 
however, associated with the extreme exhaustion, which is characteristic of 
this disease, the temperature may fall and remain below normal with per- 
haps but slight variations. 

The hemorrhagic symptoms of sepsis are of great importance. Besides 
the purpura above noted, hemorrhages may occur from nasal, buccal, in- 
testinal and other mucous membranes. Under the heading Hemorrhages 
in the New-Born the hemorrhagic syndromes of sepsis, which present more 
or less distinct clinical pictures, are described. 

Nervous symptoms of sepsis vary greatly in different cases. As a rule, 
extreme prostration is associated with apathy and stupor leading up to 
profound coma. In other instances, especially where the meninges and 
cerebral centers are involved, there are sleeplessness, extreme irritability, 
muscular twitchings, localized paralyses and finally convulsions. 

In addition to the widely varying symptom group above detailed, we 
may have, as symptoms of sepsis in the new-born, purulent arthritis, osteo- 
myelitis, pericarditis and, very rarely, endocarditis and nephritis. Albu- 
minuria, associated with occasional hyalin and granular casts, is a very 
common finding. Purulent vaginitis and conjunctivitis may occur. 

Diagnosis. — The diagnosis of septic infection in the new-born is oft- 
times extremely difficult, since there is no clearly defined clinical syndrome 
which can be relied upon to definitely indicate this disease. The physician, 
however, should always keep in mind the fact that severe and dangerous 
gastrointestinal, pulmonary and meningeal symptoms occurring at this time 
of life are strongly indicative of sepsis. The cases most difficult of diag- 
nosis are those presenting the symptoms of pneumonia, gastroenteritis and 
meningitis. In the majority of cases there is external evidence either at the 
umbilicus or on the skin or mucous membranes, which indicates that the 



PLATE II. 




Blood Picture in Dermatitis Exfoliativa. 
(Drawn by Dr. A. E. Osmond). 



DERMATITIS EXFOLIATIVA 



79 



infant may be suffering from septic infection. The symptoms which es- 
pecially call attention to this condition are great and unexplained prostra- 
tion, associated with jaundice, septic temperature and hemorrhages of the 
character above noted. The blood examination may show a marked leuko- 
cytosis. Blood cultures which might demonstrate positively not only the 
existence of a general septic infection, but the causative organism as well, 
cannot be resorted to in infants of this age as a routine method of diagnosis. 
Prognosis. — This is very grave; nearly all severe cases rapidly succumb. 
Death may occur within a few days, or it may be postponed for a week or 
more. Many of the milder cases, especially those having their origin in 
umbilical infection, recover. The prognosis is altogether unfavorable in 
the pulmonary, gastrointestinal and meningeal cases. 

DERMATITIS EXFOLIATIVA 

Symptomatology. — This interesting and comparatively rare syndrome 
described by Ritter was believed by him to be a manifestation of septic 



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Fig. 15.- 



-Blood Chart in a Case of Dermatitis 
Exfoliativa. 



infection in the new-born. It makes its appearance between the first and 
the third week of life. In the beginning the skin of almost the entire body 
begins to show hyperemia with more or less swelling and superficial inflam- 
mation, and fissures appear at the angles of the mouth. This latter symp- 
tom is important and quite characteristic when taken in connection with 
the general skin eruption. As the dermatitis proceeds the skin becomes 
thicker, more edematous and covered with large flaky scales of epithelium, 
which are partly detached and which give to the whole body a characteristic 
scaly appearance. These scales may be removed in large flakes, exposing the 
7 



80 DISEASES OF THE NEW-BORN" 

congested skin beneath. If recovery occurs, as it does in some instances, 
this flakiness of the skin gradually diminishes and in the course of a few 
weeks entirely disappears. In the great majority of cases, however, the 
disease is associated with symptoms of general sepsis and the prognosis in 
these cases is bad. In a case recently observed by me the dermatitis exfoli- 
ativa occurred as a symptom of general sepsis following umbilical infection, 
and the blood picture in this case was interesting and remarkable. This 
blood picture, so far as the large number of eosinophiles was concerned, 
was perhaps due to the skin lesion. The marked leukocytosis was perhaps 
a symptom of the general sepsis. The blood picture in this case is here 
presented. 

Treatment. — There is perhaps no treatment which materially influences 
the course of general sepsis in the new-born. Unguentum Crede, as an 
inunction, may be thoroughly rubbed through the skin twice in every 
twenty-four hours; the technique for its administration is given in detail 
in the chapter on Scarlet Fever. Any disease of the umbilicus or of the 
skin or mucous membranes of the mouth should have appropriate treatment. 
In umbilical infection, the wound is to be washed out with a 1 to 4 solu- 
tion of peroxid of hydrogen or a 1 to 1,000 solution of bichlorid of mer- 
cury. Following the use of these disinfectants the part is to be carefully 
dried and covered with aristol, or some other antiseptic powder, which is 
held in place by a gauze pad and proper bandages. External wounds and 
ulcers of the skin should be treated in much the same way. The infant, if 
not able to nurse, is to be fed with breast milk from a medicine dropper, 
and given from ten to fifteen drops of whiskey in two teaspoonfuls of water 
every three hours. 

The prophylactic treatment of this condition is of the greatest impor- 
tance and is altogether in the hands of the obstetrician. The infant should 
be delivered and handled with clean hands, and immediately following its 
birth should be bathed in clean, warm water, great care being taken to 
protect the eyes, the nose and the mouth of the child. If the obstetrician 
knows of vaginal conditions in the mother which predispose the unborn 
child to sepsis, even greater care must be exercised to prevent infection 
during labor; saline vaginal douches may be of value in such cases. Fol- 
lowing the tying of the cord the umbilical region must from time to time 
be carefully inspected, and if evidences of acute inflammation develop, or if 
pus appears, the antiseptic treatment above noted for the relief of this con- 
dition should be resorted to. 

Infants should not be allowed to nurse breasts with infected fissures 
or in which there has already developed an abscess or localized inflamma- 
tory swelling. 

ERYSIPELAS 

The specific organism of this disease has not been isolated. It is be- 
lieved to be an inflammation of the skin and mucous membranes produced 
by septic cocci, and the characteristic redness and edema are perhaps due to 






ERYSIPELAS 81 

the location of the septic inflammation in the skin and subcutaneous tissues. 
It is produced by septic virus coming in contact with an open wound, or 
with some abrasion of the skin or mucous membrane. This inoculation 
most commonly occurs during the first two weeks of life through the 
umbilical wound, but it may occur through abrasions of the skin and 
mucous membranes about the nose, genitalia and other portions of the 
body. 

Symptomatology. — Erysipelas manifests itself by a well-marked redness 
and swelling of the skin, which in the new-born commonly occur about 
the umbilicus. Because of the feeble resistance of the infant to this dis- 
ease the inflammation spreads rather rapidly through the skin and subcu- 
taneous tissues around the umbilicus and over the lower portion of the 
abdomen and may extend to the lower extremities. When the infection 
starts at the umbilicus the inflammation spreads downward, although in 
some instances it may involve the skin of the chest, face and upper ex- 
tremities. When the erysipelas begins at the angle of the nose or some 
portion of the face it spreads rapidly over the face and head of the infant 
and thence downward, involving the skin of the chest and other portions 
of the body. Facial erysipelas in the infant, unlike that in the adult, is 
not, as a rule, limited to the face and head. 

Erysipelas in the infant frequently results in a general sepsis, pro- 
ducing peritonitis, pneumonia and other septic infections of internal organs, 
and the subcutaneous tissues, more commonly than in the adult, are in- 
volved in a phlegmonous inflammation. The constitutional symptoms are 
usually severe. High fever, marked prostration, intestinal disorders, som- 
nolence and even convulsions may occur. 

Prognosis. — The younger the child the more unfavorable the prognosis. 
Umbilical infections are commonly more serious than those occurring in 
other parts of the body. In children over one year of age the prognosis 
is usually good, the disease running its course and terminating in recovery 
in much the same manner as it does in the adult; during the first weeks 
of life it is a very fatal disease. The great majority of these cases die from 
general sepsis. 

Treatment. — The treatment of erysipelas in the young infant is very 
unsatisfactory. Every effort should be made to nourish the child with 
breast milk. In view of the fact that these cases are commonly complicated 
by intestinal disturbances the infant should from the beginning be fed as 
though it had gastroenteritis, and medicines, such as the tincture of the 
chlorid of iron, which may produce gastric disturbance, should not be 
given. Whiskey, well diluted, may be used throughout the disease. Ichthyol 
ointment, one drachm to the ounce of lanolin, is almost universally recom- 
mended as a local application. It relieves the irritation of the skin and 
thereby diminishes the nervous irritability of the child, but it does not have 
any specific influence in controlling or checking the spread of the inflam- 
mation. Antistreptococcic serum in from 2 to 5 c.c. doses, given hvpo- 
dermically at intervals of six or eight hours, is of value in some cases. 



82 DISEASES OF THE NEW-BORN 

Unguentum Crede should be given by inunction in all cases. This oint- 
ment should be thoroughly rubbed into the skin of the unaffected portions 
of the body twice in twenty-four hours. I believe that this treatment may 
be of material advantage in controlling the sepsis in many cases. 

HEMORRHAGES IN THE NEW-BORN 

There are a number of clinical syndromes, occurring in the new-born, 
in which hemorrhage is the most striking symptom. All of these syn- 
dromes are believed to be due to some kind of infection, but they differ 
somewhat from the clinical pictures of septic infection just described. It 
is to be remembered, however, that ordinary sepsis is the most common 
cause of spontaneous hemorrhage in infants just after birth, and it is also 
to be remembered that hemorrhages may very rarely occur from congenital 
hemophilia and from unknown causes which are apparently not septic in 
their origin. In all of these conditions the hemorrhages are due primarily 
to impaired blood coagulation ; the exciting traumas are insignificant. 

EPIDEMIC HEMOGLOBINURIA 

(WincJceVs Disease) 

Epidemic hemoglobinuria, which is elsewhere noted, is characterized by 
a well-marked hemoglobinuria, great depression and icterus. The urine is 
dark red in color and contains besides hemoglobin a small amount of albu- 
min with occasional casts. 

ACUTE FATTY DEGENERATION OF THE NEW-BORN 

(BuliVs Disease) 

Acute fatty degeneration of the new-born is a rare septic syndrome, 
in which there may be hemorrhages from the umbilicus or from the gastro- 
intestinal, conjunctival and buccal mucous membranes, or petechial hemor- 
rhages may occur beneath the skin. Asphyxia, icterus, and edema are com- 
monly present; the spleen and liver are enlarged. There is early and pro- 
found prostration ending in death within one or two weeks. In this con- 
dition the heart, liver and kidneys undergo a rapid fatty degeneration, and 
hemorrhages may occur in these organs. 

MELENA NEONATOEUM 

Melena neonatorum is a term used to cover a septic syndrome, the 
characteristic symptom of which is bleeding from the gastrointestinal canal. 
In these cases blood is discharged from the rectum and is ejected from the 
stomach. The hemorrhage occurs during the first few days of life and the 
first symptom commonly noticed is the discharge from the bowels of dark- 
red or black material, which on examination is found to be blood. In the 
later discharges the blood, not remaining in the intestinal canal so long, is 
not so dark in color. In those cases where the bleeding continues vomiting 
of blood occurs and the blood continues to be discharged through the rectum. 



HEMOEEHAGES IX THE NEW-BOKN 83 

The child becomes more and more prostrated, its pallor deepens, the heart 
sounds become more and more feeble, and death occurs from exhaustion. 
There are, however, a considerable number of cases in which there is but 
little or no recurrence of the hemorrhage after birth. In these cases the 
infant may discharge by the rectum brown or black discharges mixed with 
mucus and fecal matter, an examination of which shows that this discolora- 
tion of the fecal discharges is due to blood. These cases may run a benign 
course, the dark-brown discharges colored with blood may continue from 
four to five days, gradually diminishing in frequency and gradually losing 
their dark color, and thereafter the child may show no evidence of disease 
of any kind except perhaps a slight intestinal indigestion, which may con- 
tinue for some weeks. It is very questionable whether these benign cases 
are septic in origin; it is much more probable that the hemorrhages are 
due to injuries received during birth. Even severe cases of intestinal 
hemorrhage, which have continued for more than a week, may recover. 
The bleeding in some instances stops spontaneously, and the infant makes a 
slow but satisfactory recovery, and thereafter it may never manifest any 
hemorrhagic tendencies or constitutional taints to explain the symptoms 
from which it suffered during the first days of life. A number of these 
cases have come under my observation. 

CONGENITAL SYPHILIS 

Congenital syphilis may have among its earliest manifestations hemor- 
rhages from the nose, mouth and other mucous membranes. In fact, when 
hemorrhage occurs during the first days of life from the nose of an infant 
it is well to suspect and look for other symptoms of congenital syphilis. Pro- 
nounced and troublesome umbilical hemorrhages are nearly always septic 
in their origin. 

PEOGNOSIS OF HEMOEEHAGE 

This depends upon the location, the severity and the cause of the hemor- 
rhage. In Winckel's and Buhl's diseases the prognosis is bad. In ordinary 
sepsis of umbilical origin hemorrhage is an unfavorable symptom and com- 
monly means a fatal termination. In hemorrhages from the nose or buccal 
mucous membrane due to syphilis the hemorrhage can usually be controlled 
by the local application of a solution of adrenalin, and the prognosis will de- 
pend upon the severity and extent of other syphilitic lesions. In melena 
neonatorum (hemorrhage from the gastrointestinal canal) the prognosis is 
very grave and will depend in part upon the presence of other symptoms of 
sepsis. 

TEEATMENT OF HEMOEEHAGE 

Hemorrhages from the mouth and nose may be controlled by the local 
application of adrenalin solution, and gastrointestinal hemorrhages may 
sometimes be modified or controlled by the internal administration of 
adrenalin in 2 or 3-grain doses given at intervals of two or three hours. 
Ten per cent, sterile gelatin solution injected subcutaneously (15 c. c.) has 



84 DISEASES OF THE NEW-BORN 

also been strongly recommended in these cases. These infants should be 
kept as quiet as possible and no foods or fluids given except water until 
the hemorrhage is controlled ; then small quantities of breast milk at four- 
hour intervals may be allowed. Cathartics are to be avoided and enemata 
used only when it is necessary to evacuate the bowels. 

Hemorrhagic diseases in the new-born have been successfully treated 
by direct transfusion of human blood (Carrel) ; the technique of this op- 
eration, however, is difficult and for this reason it is not always practicable. 
They have also been successfully treated by injections of the normal serum 
of human blood. This method was introduced by J. E. Welsh and has 
been used by many other observers. The blood serum is obtained from hu- 
man blood withdrawn and cared for under sterile conditions. Ten to thirty 
c. c. should be injected subcutaneously two or three times a day as long as 
the bleeding continues, and the same treatment should be resumed if the 
hemorrhage returns. Following both the transfusion of human blood and 
the subcutaneous injections of human blood serum, improvement begins at 
once and the hemorrhage is usually controlled within one or two days. In 
the great majority of these cases a permanent cure results; in a few, how- 
ever, the benefit derived is of short duration; the hemorrhage returns and 
the disease goes on to a fatal termination. These methods of treatment 
should therefore be used in all severe cases of hemorrhagic disease in the 
new-born. 

DISEASES OF THE UMBILICUS 

After ligation the stump of the umbilical cord undergoes mummifica- 
tion and comes off about the fifth or the sixth day. In premature and con- 
genially weak children this process is somewhat delayed. After separation 
of the cord the skin of the umbilicus folds inward so as to protect and cover 
the umbilical wound until an epithelial coating makes it less susceptible to 
injury and infection. 

INFECTION OF THE NAVEL WOUND 

Infection of the navel wound occurs during the first few days of life, 
either before or just following separation of the stump of the cord. The 
manner in which this infection may occur and its causes are discussed under 
Septic Infection in the New-Born. Omphalitis may be mild or severe. 
Eedness, swelling, and infiltration of the umbilicus are here more or less 
marked, and a seropurulent or purulent discharge soon makes its appear- 
ance. The skin around the umbilicus may be excoriated and the subcu- 
taneous tissues may become infected so that abscesses may form. As the 
inflammation subsides the umbilical pocket may be the site of an ulcer; 
in this condition the parts remain tender, somewhat swollen and continue 
to discharge pus. 

Umbilical Vegetations. — Umbilical vegetations, or granuloma, are a not 
uncommon result of infection of the umbilicus. After the stump of the 
cord has fallen off a small red granulating mass is noticed, which gradually 
increases in size, protruding through the umbilical opening. This small 



DISEASES OF THE UMBILICUS 85 

red tumor is associated with a serous discharge not infrequently tinged 
with blood. This tumor may become as large as the end of one's finger ; it 
is commonly pedunculated and is bright or dark red in color. 

Gangrene of the Umbilicus. — Gangrene of the umbilicus is rare and 
occurs most commonly in feeble, malnourished children. In this condition 
the umbilical wound assumes the appearance of ordinary gangrene. The 
gangrenous process spreads not only into the surrounding skin and subcu- 
taneous tissues, but also involves the umbilical vessels and produces a fatal 
peritonitis or sepsis. 

Infection of the navel wound resulting in inflammatory processes may, 
as previously noted, involve the umbilical vein and the umbilical artery, 
producing phlebitis and arteritis, and thereby readily leads to general septic 
infection of the new-born. 

Treatment of Infections. — The prophylactic treatment is purely obstet- 
rical and consists in the proper care of the cord. A few minutes following 
delivery, after normal respiratory efforts have been established, and the 
change in circulation has occurred, the cord is to be carefully ligated with 
tape and then cut. This should be done with clean hands and clean instru- 
ments. Following the bathing of the infant, the cord is to be dressed with 
proper surgical precautions, and thereafter redressed as often as may be 
necessary to keep the wound clean and prevent infection. If more than 
the normal amount of inflammatory reaction occurs in the umbilical wound, 
either before or after the separation of the stump, it is to be carefully 
cleansed with a 1 to 1,000 bichlorid solution or with a 1 to 4 peroxid of 
hydrogen solution and then covered with some antiseptic powder, which is 
to be held in place by a pad of gauze, covered with absorbent cotton and a 
retaining bandage. The importance of promptly treating all umbilical 
infections by the most approved surgical methods has been emphasized in 
the treatment of Septic Infections of the New-Born. Where abscesses occur 
they are to be opened and properly drained. Ulcers may be treated with 
weak astringent powders or they may be cleansed and treated with a % 
per cent, solution of nitrate of silver. Granuloma should be cauterized with 
the solid stick of nitrate of silver. If they do not yield to this treatment 
they should be curetted or cut away, and the wound thus produced covered 
with aristol or some other antiseptic powder, held in place by pieces of 
gauze and adhesive plaster. 

UMBILICAL HEMOEEHAGE 

A slight umbilical hemorrhage may occur from improper ligation of the 
cord, from its premature separation, or from injury to the umbilicus dur- 
ing the early days of life. Hemorrhages of this character are easily con- 
trolled and are of little pathological importance. The change in the cir- 
culation which occurs at birth so diminishes the blood pressure in the blood 
vessels of the cord that serious traumatic hemorrhage, occurring in an 
otherwise normal infant, is always a matter of gross negligence on the 
part of either the nurse or the physician. Persistent hemorrhage from the 



86 



DISEASES OF THE NEW-BOEN 



"umbilicus which fails to yield to simple treatment is therefore a matter of 
grave import and indicates serious constitutional disorder which has af- 
fected the capillary circulation of these parts in such a way that normal 
coagulation of the blood cannot be induced for the stopping of the hem- 
orrhage. Hemorrhage of this character may, as previously noted, be a 
symptom of septic infection in the new-born or it may be one of the early 
manifestations of syphilis or hemophilia. It is sometimes associated with 
pronounced jaundice. It is always an indication of profound and danger- 
ous constitutional disturbances and is frequently accompanied by other 
evidences of a general hemorrhagic diathesis, such as hemorrhages from 
other mucous membranes and petechial hemorrhages into subcutaneous 
tissue. 

Treatment. — The simple forms are readily controlled by bandages mak- 
ing pressure over the part, which may be saturated with a 1 to 1,000 adrena- 
lin solution. The grave forms of hemorrhage, however, are to be treated 

as recommended under 
Septic Infections in the 
New-Born. The syphi- 
litic cases should receive 
anti-syphilitic treatment. 

UMBILICAL HERNIA 

A slight dilatation of 
the umbilical ring, with 
protrusion of the intes- 
tine forming a small tu- 
mor the size of the end of 
one's little finger, is very 
common in premature 
and congenitally weak in- 
fants. It also occurs in 
older infants who are 
rachitic or exceedingly 
malnourished, and who 
have suffered from gas- 
trointestinal disturb- 
ances, resulting in 
marked abdominal dis- 
tention. Slight hernias, 
both umbilical and in- 
guinal, are very com- 
monly seen in pot-bellied, 
malnourished, rachitic 
infants. These protrusions are greatly aggravated by crying and coughing. 
Treatment. — In the form of umbilical hernia which makes its appear- 
ance just after birth the prognosis is good and the treatment is simple. 




Fig. 16. — Umbilical Heknia. 



HOLT'S INANITION FEVEE 87 

The ordinary abdominal bandage of the infant holding a pad of gauze over 
the umbilicus may be applied more snugly than usual. This is all that is 
necessary during the first few weeks of life. Later the hernia should be 
reduced and 'held within the abdominal walls by a strip of adhesive plaster. 
This strip of plaster should extend across the abdomen and as it is applied 
the abdominal walls at the umbilicus should be folded in a vertical direction 
over the umbilicus, so that the approximated folds held by the adhesive 
plaster cover the umbilicus and prevent the hernial protrusion. The ad- 
hesive plaster should be renewed every three or four days, and if ulceration 
or irritation of the umbilicus or of the surrounding skin has occurred the 
treatment is to be discontinued until these parts have been entirely healed. 
The hernia in these cases may also be held in by making a round pad of 
thin wood about the size of a quarter, covering it with a piece of soft cloth 
and holding it in position over the umbilicus with adhesive plaster. With 
treatment of this kind applied over a period of five or six weeks, the umbili- 
cal opening commonly closes and a permanent cure results. In some in- 
stances, especially in malnourished infants, the hernia persists throughout 
infancy and perhaps gradually increases in size. A surgical operation is 
necessary for the cure of these cases. 

There is a rare and much more serious form of congenital hernia, due to 
arrested development. In these cases the hernial sac at birth may be very 
large and filled with intestines and occasionally other abdominal organs, 
such as the liver, spleen, and kidney. These cases demand immediate sur- 
gical interference. 

MASTITIS 

Enlargement of one or both mammary glands in the new-born is a not 
uncommon occurrence. It is most frequently seen during the second week 
of life. These swollen glands may secrete a milk-like substance, and on 
palpation they are found to be caked and more or less tender. In the 
majority of instances this tumefaction gradually disappears; the breasts 
become less tender, less swollen, and by the end of the third week of life 
have resumed their normal proportions. In other instances an infection 
of the gland occurs which -causes it to become more inflamed, red, and 
swollen. This may produce a slight fever and after a number of days 
fluctuation may be discovered. 

Treatment. — Previous to suppuration the swollen breasts are to be cov- 
ered with gauze or lint, saturated with a weak solution of bichlorid of 
mercury, which is to be held in position by a carefully adjusted bandage. 
When fluctuation is discovered it is to be treated as any other abscess, by 
incision, proper drainage, and careful cleansing with antiseptic solutions. 

HOLT'S INANITION FEVER 

Under the term "inanition fever" Holt has described a distinct clinical 
syndrome characterized by fever and nervous irritability. It occurs dur- 
ing the first five days of life. 



88 DISEASES -OF THE NEW-BOKN 

Etiology. — The term "inanition fever/' as Holt says, is not a satisfac- 
tory one. It is probably an autointoxication, due to the failure of the newly 
born infant to get sufficient fluid from the breast to flush out its kidneys 
and other excretory organs. It is clearly evident that the condition is 
commonly due to a deficiency in the breast milk. It disappears quickly 
when the milk secretion is established or when the infant is given water in 
sufficient quantities. Apart from determining the exact pathological cause 
of this syndrome there is little to add to the very clear description of its 
etiology, symptomatology, and treatment as given by Holt. 

Symptomatology. — Holt says: "The symptoms are so uniform and so 
characteristic that they make for these cases of fever a class by themselves. 
The frequency with which this is seen is shown by the following statistics : 
Among two hundred infants taken successively at the Nursery and Child's 
Hospital twenty had fever during the first five days, reaching 101° F. or 
over, which was not explained by ordinary causes. In five hundred suc- 
cessive children born at the Sloane Maternity Hospital there were one hun- 
dred and thirty-five with a similar fever. It was seen in vigorous infants 
as well as in those who were delicate. The usual duration of the fever was 
three days, the temperature generally reaching the highest point upon the 
third or fourth day of life. In about two-thirds of the cases the tempera- 
ture did not rise above 102° F. ; in nine it was 104° F. or over, the highest 
recorded being 106° F. The fall was generally quite abrupt, although not 
always so. Daily weighings showed that the infant continued to lose 
weight while the fever continued and that the loss almost invariably ex- 
ceeded by several ounces that of children who had no fever. The maximum 
loss noted was twenty-eight ounces. In quite a large number of cases it 
exceeded twenty ounces. As a rule, the infant began to gain in weight 
when the temperature remained at the normal point, but not until then. 

"The symptoms presented by these infants were a hot, dry skin, marked 
restlessness, dry lips, and a disposition to suck vigorously anything within 
reach. With very high temperature there was considerable prostration and 
weakened pulse. In the less severe cases there were only crying and rest- 
lessness. The rapidity with which the symptoms disappeared when the 
children were wet-nursed or properly fed was very striking." 

In addition to this symptom group I have commonly observed in these 
cases a marked diminution in the urinary secretion and occasionally anuria 
over a period of twenty-four or thirty-six hours, to be followed by the dis- 
charge of a small quantity of highly colored urine, occasionally tinged with 
blood. 

Diagnosis. — This condition can scarcely be mistaken for anything except 
sepsis in the new-born. Holt's fever occurs during the first five days of 
life ; sepsis occurs most commonly during the second week and occasionally 
later. The promptness with which Holt's fever responds to proper treat- 
ment and the seriousness of the septic syndrome with continuance of the 
fever, prostration, and other associated symptoms make the diagnosis 
clear. 






TETANUS NEONATORUM 89 

Prognosis. — This is good. All of these cases make a satisfactory re- 
covery as soon as the proper treatment is instituted. 

Prophylaxis. — In view of the prevalence of this condition, all infants 
during the first few days of life should be given small quantities of water 
at frequent intervals and special attention should be given to the condition 
of the mother's breasts, to ascertain whether the milk secretion is being 
established at the normal time. In cases where there is a delayed estab- 
lishment of the milk secretion weak solutions of skimmed milk, 1 to 4, or 
breast milk should be given until the milk secretion of the mother has been 
fully established. 

Treatment. — The curative treatment of this condition, as Holt has said, 
is to give the infant water at short intervals and to supply it with food in 
the form of breast milk from a wet-nurse or with weak mixtures of cow's 
milk. In the event that the secretion of milk in the mother's breast is not 
properly established, the infant should be fed permanently upon the breast 
milk of a properly selected wet-nurse. 



CHAPTER VIII 

DISEASES OF THE NEW-BOEN {Continued) 

TETANUS NEONATORUM 

Tetanus of the new-born, like tetanus in the adult, is an acute infection 
produced by the tetanus bacillus. 

Etiology. — The tetanus bacillus finds its portal of entrance at the um- 
bilical wound, and in this pocket it multiplies rapidly and forms its specific 
toxin (tetanotoxin), which is rapidly disseminated throughout the body. 
The tetanus toxin has a special predilection for nerve tissue and probably 
unites in organic combination with the material forming the motor cells 
of the spinal cord and medulla. This produces an intense reflex excitabil- 
ity and irritability of the motor cells of the spinal cord and of the medulla 
oblongata. The irritability of these tissues becomes so great that the 
slightest reflex cause will excite violent tonic muscular contractions. The 
tetanus bacillus is believed to confine itself almost entirely to the umbilical 
pocket and there produce the toxin, the absorption of which is responsible 
for the profound toxic symptoms of this disease. The fact, however, that 
the blood of patients suffering from tetanus is capable of transmitting the 
disease when injected into animals indicates that along with the toxin thus 
injected there must be at least a few tetanus bacilli. 

The tetanus bacillus is found in the superficial layers of the earth and 
is much more prevalent in some localities than in others. 

Tetanus is most common among the class of people who live in un- 
cleanly surroundings. It is a dirt or filth-borne disease and is carried to 
the umbilicus by dirty hands, dirty clothing, or by anything that may carry 



90 DISEASES OF THE NEW-BOEN 

dust or other dirt to the wound. With individuals living amidst dirty 
surroundings it is possible that the tetanus bacillus may be carried through 
the air on particles of dust to the umbilical wound, which, especially after 
the stump of the cord has been separated, furnishes so suitable a soil for its 
growth. In rare instances the tetanus bacillus may find an entrance 
through wounds or raw surfaces other than that of the umbilicus, but that 
this is a very unusual occurrence is indicated by the fact that tetanus in 
the young infant is confined almost exclusively to the first three weeks of 
life, when the umbilical wound is still open. It may occur during the 
first days of life, but is much more common during the second week, when 
the cord has separated and the umbilical wound is open. It becomes less 
frequent during the third week of life as all irritation about the umbilicus 
gradually disappears, and after the third week, with the umbilical wound 
entirely healed, it is very rare. 

Symptomatology. — Nervousness, irritability, and sleeplessness are the 
usual premonitory symptoms. These are followed by difficulty in nursing; 
the child lets go of the breast with a sudden cry after a few attempts at 
sucking. The lower jaw gradually loses its motility and in putting the 
child to the breast it is noticed that there is a firm and tonic contraction of 
the muscles which causes it to become locked in such close proximity to 
the upper jaw that food, water, and medicines can be introduced into the 
mouth only by means of a medicine dropper. This condition of trismus is 
an early and characteristic symptom in practically every case of tetanus 
neonatorum. In the beginning these muscular spasms are followed by 
periods of relaxation, but, on attempting to feed the infant by putting the 
nipple or a spoon between its gums, the lower jaw is again thrown into a 
condition of spasm. These attacks of trismus continue to recur with 
greater frequency and are more prolonged as the disease advances, so that 
within a short period of time, usually a few days, the lower jaw is con- 
tinuously locked in close proximity to the upper jaw by the tonic muscular 
contractions. 

Spasms of the muscles of the face, which soon become associated with 
the trismus, produce a very characteristic expression. The forehead is 
wrinkled, the eyes closed, and the mouth puckered. Gradually the muscles 
of the neck, back, abdomen, and extremities are affected, and the tetanic 
contraction of these muscles produces retraction of the neck, opisthotonos, 
and stiffness of the entire body. All the joints of the arms and legs are 
in a condition of flexion. The^ muscular rigidity reaches its maximum in 
from one to three days. In severe cases the child may die before the lower 
extremities are involved or in mild cases recovery may occur without the 
disease extending to the arms and legs. Swallowing becomes more difficult 
and finally impossible; respiration is embarrassed as a result of spasm of 
the diaphragm. Throughout the disease the tetanic contractions are 
greatly exaggerated by slight reflex causes, such as attempting to feed the 
child or handling it for absolutely necessary purposes. 

The temperature is of no diagnostic value. At the onset and just before 



TETANUS NEONATORUM 91 

death it may be as hign as 105° or 106° F. During the course of the dis- 
ease it may be subnormal. The child lies in the rigid condition above 
described, making no outcry because of the spasm of the laryngeal muscles ; 
its breathing becomes more and more superficial and irregular; its pulse 
more feeble and rapid; the muscles of its body become more continuously 
and more rigidly contracted, until death occurs from asphyxia or exhaus- 
tion. In those cases which are fortunate enough to recover there is a 
gradual recession of the symptoms, tne period of relaxation between the 
spasms becomes greater and the trismus is less marked, and the child less 
readily responds to reflex excitation. 

Diagnosis. — There should be no difficulty in the diagnosis of tetanus in 
infancy. The only conditions for which it may be mistaken are meningitis 
and brain injuries producing spastic paralysis, and sometimes opisthotonos, 
but in these cases the characteristic symptom of trismus is absent and the 
tonic muscular contractions do not recur in spasms excited by slight reflex 
stimuli. 

Prognosis.— Nearly all of these cases die. By some writers the per- 
centage of recovery is placed as high as 30 per cent, and others report only 
2 or 3 per cent, of recoveries. 

Treatment. — The prophylactic treatment pertains to the care and man- 
agement of the stump of the cord and of the navel wound which results 
from its sloughing off. This treatment is of special importance in infants 
who are born under dirty surroundings; that is to say, under conditions 
where there is a probability or possibility that the navel wound may be 
inoculated with filth, dust, or dirt containing the tetanus bacillus. The 
prophylactic treatment, therefore, is purely obstetrical, and all of the con- 
ditions necessary to absolute asepsis should be rigidly enforced in cutting 
the cord, ligating the stump, and dressing the wound. All of this must 
be done with clean hands, clean instruments, and afterward the navel is to 
be so dressed with a dry antiseptic dressing that it is impossible for it to 
be contaminated by dirty surroundings. It is especially important to re- 
member that the navel wound is to be dressed and redressed for three 
weeks, or until it has entirely healed. It is during the second week after 
the cord has sloughed off that the navel is to be especially protected from 
contamination with anything that may act as a carrier of the tetanus 
bacillus. If infection of the umbilical wound occurs it is to be carefully 
washed out with a 1 to 4 solution of peroxid of hydrogen or a 1 to 1,000 
solution of bichlorid of mercury, then carefully dried, and dressed with 
some antiseptic powder. 

In the treatment of the disease itself it is wise to use tetanus anti- 
toxin with the onset of the first symptoms. This antitoxin can do no 
harm even in large doses. It acts by combining with the toxins of this 
disease and thereby neutralizing their poisonous effect upon the nerve 
centers. To be of benefit, therefore, it must be given early and in large 
doses. It is commonly introduced by lumbar puncture into the spinal 
canal or into the subcutaneous tissues in the same way as diphtheria anti- 



92 DISEASES OF THE NEW-BOKN 

toxin. From 5 to 10 c. c. may be introduced into the spinal canal, follow- 
ing a lumbar puncture which has drained away that amount of fluid. The 
technique of this operation is exactly the same as that used for introducing 
anti-meningitis serum in cerebrospinal meningitis. At the same time 10 
or more c. c. of antitoxin may be introduced subcutaneously. The subcu- 
taneous injection may be repeated at intervals of six hours and the spinal 
canal injection at intervals of twenty-four hours for two or three days. If 
no appreciable result has then been produced by the treatment it should 
be discontinued. 

The symptomatic treatment consists in keeping the child as quiet as 
possible, touching it only when necessary, and shielding it from all noises. 
Its nourishment should be breast milk. When it can no longer nurse the 
breast it should be fed breast milk with a medicine dropper, or the same 
food may be introduced into the stomach through a catheter which is 
passed through the nose and down the esophagus. When these children, 
however, have reached a stage when deglutition is impossible, little is to be 
accomplished from introducing food in this way. 

Chloral is by far the most valuable drug for controlling the muscular 
contractions and making the patient more comfortable. It is to be given 
in 1 or 2-grain doses every two or three hours, as indicated, to relieve the 
symptoms. When the infant can no longer swallow, chloral, in 2 to 4- 
grain doses, should be given by the rectum. In milder cases bromid of 
potash may be used with or instead of the chloral. 

ICTERUS NEONATORUM 

This is the form of jaundice so common in the new-born. It runs a 
benign course and is of importance from the standpoint of differential 
diagnosis. It must be differentiated from the grave forms of jaundice 
due to occlusion of the bile ducts and to the jaundice which occurs as a 
symptom of sepsis and cirrhosis of the liver. 

Etiology. — The etiology of icterus neonatorum remains obscure, not- 
withstanding the many ingenious theories which have been offered in its 
explanation. It has been suggested that the excessive destruction of red 
blood corpuscles during the first days of extrauterine life and the abundant 
blood supply to the liver at this time cause the liver to form an excess of 
bile, part of which is reabsorbed, passes into the blood stream and produces 
jaundice. A part, however, of this excess of bile passes through the bile 
ducts into the intestine, and for this reason the intestinal symptoms, which 
are such an important part of the symptom complex in obstructive jaundice, 
are almost or entirely absent in this condition. This form of jaundice can 
scarcely be spoken of as a pathological condition, since it is the result of 
physiological causes acting under new and perhaps exaggerated conditions. 
It occurs to a greater or less degree in from 60 to 80 per cent, of all newly 
born infants, and some observers place this percentage even higher. It is 
more common, or at least more severe and prolonged, in feeble, mainour- 



ICTERUS NEONATORUM 93 

ished infants, and especially in those born prematurely. For this reason 
it is more commonly seen in public maternity hospitals and foundling in- 
stitutions than in private practice. 

Symptomatology. — The jaundice may appear a few hours after birth, 
but is commonly not recognized until the second or third day. It remains 
at its height but a few days and then begins to slowly disappear, so that in 
the great majority of cases no trace of it is left after the eighth or ninth 
day. In some instances, however, the jaundice may persist for several 
weeks. This is much more likely to occur in premature and malnourished 
infants. The sallowness makes its appearance first on the face, chest, and 
back, and in the more marked cases the yellow color deepens and the jaun- 
dice extends to other parts of the body. The constipated, putrid, clay- 
colored stools, so characteristic of obstructed jaundice, are nearly always 
absent. The discharges from the intestinal canal are almost normal, or 
perhaps modified in the more marked cases by slight intestinal indigestion. 

The conjunctiva is slightly tinged with yellow, but not so markedly as 
in obstructive jaundice. The diagnosis in this form of jaundice is made 
rather by the sallowness of the skin than by the yellowness of the con- 
junctiva. When the jaundice is at its height, however, in the marked 
cases, the conjunctiva has a distinctly yellow color. The urine in such 
cases is dark in color and produces a dark yellow stain on the napkins, and 
bile can sometimes be demonstrated in it by the ordinary chemical tests. 
The discoloration of the urine, however, and its reaction to the ordinary 
tests for bile is never so marked in this condition as in obstructive jaundice, 
and early and late the urine may furnish no evidences of containing bile. 

Infants with icterus neonatorum present no constitutional symptoms of 
illness. They are, as a rule, happy, take their food in a normal manner, 
and, apart from the evidences of jaundice above given, are apparently well. 
The fact that premature infants and infants suffering from more or less 
profound malnutritions have a more marked and more prolonged icterus 
is an evidence that these conditions exaggerate the jaundice, rather than 
that the jaundice aggravates the malnutritions. 

Treatment. — This condition runs a benign course, terminates in recov- 
ery, and is perhaps hot influenced by therapeutic measures. It is wise, 
however, in these cases to clear out the intestinal canal with a little chalk 
mercury, followed perhaps by milk of magnesia. 

OCCLUSION OF THE BILE DUCTS 

Occlusion of the bile ducts in the new-born is rare; it may be due to 
catarrh of the mucous membrane or congenital malformations. The most 
common malformation is obliteration of the common gall duct; in some 
instances this duct may not be entirely absent, but almost occluded. The 
cystic duct and gall bladder may be rudimentary or absent. 

Symptomatology. — The symptoms are those of obstructive jaundice. 
The sallowness of the skin becomes a deeper and more pronounced yellow 
and the whole body has a markedly jaundiced hue. In rare cases where the 



94 DISEASES OF THE NEW-BOKN 

obstruction is not complete the jaundice may not be so pronounced and may 
vary in degree from time to time. These are the cases which may live for 
months, slowly dying of malnutrition. In the great majority of instances, 
however, the pronounced yellowness of the skin is associated with a well- 
marked yellowness of the conjunctiva; the urine contains bile, which may 
readily be demonstrated by ordinary chemical reactions, it is dark in color 
and stains the napkin a yellowish brown. The discharges from the intestine 
gradually become clay colored, have an offensive odor, and are, as a rule, 
dry and constipated. The liver is enlarged and not infrequently the spleen 
may be easily palpated. The child loses in weight and strength and pre- 
sents every appearance of being extremely ill. Indigestion and intestinal 
toxemia with an associated elevation of temperature are commonly present. 
As the malnutrition progresses the child becomes listless and lethargic and 
not infrequently develops a hemorrhagic diathesis. Bleeding may occur 
from mucous membranes and purpuric spots may appear over the body. 
These infants commonly die from malnutrition or autointoxication within 
a few weeks; in the less severe cases death may be postponed for some 
months. The rare cases of catarrhal jaundice may be prolonged for weeks 
and ultimately recover. 

OTHEE FOEMS OF ICTEEUS OCCUEEING IN THE NEW-BOEN 

Jaundice is a symptom of septicopyemia occurring in the new-born. 
The jaundice due to this cause is considered under Septic Infection. 

Jaundice may also occur as a symptom of congenital syphilis in the 
new-born. This is a comparatively rare cause at this period of life. The 
jaundice in this condition is due to cirrhosis of the liver. The interstitial 
hepatitis compresses the bile ducts and interferes with the outflow of bile. 
The symptoms in this form of jaundice resemble those of the milder forms 
of obstructive jaundice produced by congenital occlusion of the bile ducts. 
The skin, conjunctiva, and urine show the ordinary signs of jaundice and 
a hemorrhagic tendency may develop late in the disease; the clinical pic- 
ture produced does not in the least resemble icterus neonatorum. It is to 
be differentiated from congenital obliteration of the bile ducts by its slower 
onset, less severe and more prolonged course, but more especially by the 
existence of other evidences of congenital syphilis. 

The prognosis of syphilitic jaundice is bad. Antisyphilitic treatment 
may prolong but it cannot save the lives of these infants. 

OPHTHALMIA NEONATORUM 

Ophthalmia neonatorum is an inflammation of the conjunctiva occur- 
ring in the new-born. 

Etiology. — The gonococcus is the cause of this disease in perhaps 70 to 
80 per cent, of all cases. Infection of the conjunctiva with other pus- 
forming organisms, such as streptococci, staphylococci, and pneumococci, is 
responsible for the remaining cases. Infection results from the direct 



OPHTHALMIA NEONATORUM 95 

inoculation of the conjunctiva with one or the other of these pus-forming 
organisms and usually occurs during the birth of the child. 

Gonococcus and other forms of vaginitis and urethritis in the mother 
may produce this disease in the infant. Occasionally infection may be 
carried to the conjunctiva of the infant by the hands of the obstetrician or 
nurse, either during or after labor. 

Postpartum infection is comparatively rare and is due to gross care- 
lessness or negligence on the part of those who have the care of the infant. 
This is much more likely to occur in hospitals and other institutions than 
in private families, but the transference of septic infection from other 
patients to the eyes of healthy infants is now fortunately rare, even in 
public lying-in institutions and foundling asylums. 

Symptomatology. ■ — Since infection nearly always occurs during birth 
the symptoms commonly make their appearance before the fourth day. If 
conjunctivitis develops after the fifth day it is almost certainly due to post- 
natal inoculation. The disease announces itself with redness and swelling 
of the conjunctiva of one or both eyes. Very commonly the eyelids be- 
come so swollen and edematous that the eyes are closed and the infant no 
longer has the power of opening them. Through the palpebral fissure 
there issues a thin, yellowish discharge. When the lids are pressed apart 
by the fingers both the ocular and palpebral conjunctiva are seen to be 
violently inflamed, much swollen, gathered in folds, and covered with a 
purulent mucus. The folding of the conjunctiva is especially noticeable, 
where it crowds over the corneal margin. As the disease progresses the 
eye becomes more swollen and the discharge changes to a yellow, creamy 
pus which exudes in great profusion as the palpebral fissure is opened. At 
this stage of the disease there is great danger that ulceration of the cornea 
may occur. These ulcers may be central or marginal, the latter may be 
hidden beneath the folds of the overhanging conjunctiva. The appearance 
of corneal ulcers adds great gravity to the case. These ulcers may per- 
forate, and prolapse of the iris, loss of the aqueous humor, and panophthal- 
mitis with permanent loss of vision may result. This disease is, in fact, 
responsible for about 30 per cent, of the cases of blindness found in public 
institutions. In those cases that recover under suitable treatment, without 
corneal involvement, the first favorable indications are gradual decrease in 
the swelling and thickening of the lids. The palpebral fissure is more 
readily opened and the eye is more easily irrigated, and gradually the red- 
ness and swelling of the conjunctiva disappears. In these favorable cases 
convalescence is established within two or three weeks. 

In the gonococcus cases the inflammation is much more violent, the 
dangers of corneal ulceration greater, and the disease runs a more pro- 
longed course than in the simple cases produced by other pus-forming 
organisms. 

Diagnosis. — The differential diagnosis of gonorrheal from other forms 
of ophthalmia is made by the history of the case with reference to possible 
gonorrheal infection and by the violence of the inflammation. In doubt- 
8 



96 DISEASES OF THE NEW-BORN 

ful cases a bacteriological examination may determine the character of the 
infection. 

Prognosis. — Cases that are seen early and subjected to proper treatment, 
as a rule, terminate in complete recovery. Neglected cases, especially of 
the gonococcus type, commonly result in corneal ulceration with permanent 
loss of vision. 

Prophylaxis. — The prophylactic treatment is especially important in 
institutional practice, where gonorrheal and other forms of vaginitis are 
so commonly seen in the mother. In institutions, therefore, it is perhaps 
wise to employ in all cases the preventive treatment recommended by Crede. 
Directly after birth the child is carefully washed, and during this process 
special care should be taken to avoid contaminating the conjunctiva with 
the bath water or with wash-rags used on other parts of the infant's body. 
Following this, one drop of a 1 to 2 per cent, solution of nitrate of silver 
is carefully dropped into each eye; experience favors the weaker solution. 
In private practice the silver solution is not, as a rule, indicated unless 
the mother has a vaginal discharge. In all cases, whether in institutional 
or in private practice, where the mother has a purulent or other vaginal 
discharge the vagina, for days prior to the delivery of the child, should be 
carefully douched with alkaline antiseptics. 

In private practice where the vaginal conditions in the mother are 
normal no prophylactic treatment is necessary except the careful washing 
of the infant's eyes with a weak boric acid solution immediately after de- 
livery. Where one eye only is infected it is of the greatest importance to 
protect the other eye from inoculation. This perhaps can best be done by 
covering the well eye with cotton and lint and carefully bandaging it so 
as to prevent its accidental inoculation with the pus from the infected eye. 
Such a bandage should be removed and reapplied daily, to see that the eye 
has not become infected. 

Treatment. — The treatment of ophthalmia neonatorum is of such great 
importance that to carry it out properly requires the constant attention, 
day and night, of capable nurses, and where the inflammation begins vio- 
lently and the indications are that the disease is of gonococcic origin it is 
best to have the advice of an oculist. 

The treatment consists in the constant application of ice-cold com- 
presses. These are made of pieces of lint or gauze large enough to cover 
the eye, which are kept on a piece of ice floating in a saturated solution of 
boric acid or a 1 to 5,000 solution of bichlorid of mercury. These pieces of 
cloth are transferred from the ice to the inflamed eye every few minutes 
and changed from time to time as cleanliness demands. During this treat- 
ment, at intervals of one or two hours, the palpebral fissure should be 
opened and the pus thoroughly washed out of the eye by douching it with a 
boracic acid solution, and once in twenty-four hours a 2 per cent, solution 
of silver nitrate should be instilled into the eye. Within a few days the 
inflammation should begin to subside, and with this improvement the cold 
applications may be applied interruptedly instead of continuously, but the 



CEPHALHEMATOMA 97 

irrigations with boric acid solution and the instillations of silver nitrate 
should be continued. 

If the cornea is involved the case should be referred to an oculist. 
In these cases a 1 per cent, solution of atropin should be dropped into the 
eye from time to time until the iris is widely dilated, and throughout the 
treatment this dilatation is to be maintained. In these corneal cases the 
irrigation of the eye with mild antiseptic washes and the use of silver ni- 
trate solutions as above noted are to be continued, but the cold applications 
are of doubtful efficacy. 



CHAPTEE IX 
BIRTH INJURIES 

CEPHALHEMATOMA 

Symptomatology. — This condition is due to an injury of the sub- 
periosteal blood vessels occurring during birth. The tearing of these blood 
vessels results in the pouring out of blood between the bones of the skull 
and the periosteum. This produces a swelling of the scalp which commonly 
appears between the first and the fourth day of life. It is usually located 
over one and rarely over both parietal bones. It may be large enough to 
cover the whole, but in most instances only a part, of the parietal bone, 
and it is limited by the parietal sutures. It may reach the size of a large 
orange. The overlying skin undergoes no change nor is there any tender- 
ness or other evidence of inflammatory action. The tumor is soft and 
fluctuating, so there is never any doubt of its fluid contents. After a time, 
at the circumference of the tumor, a hard, distinct elevation forms. The 
tumor gradually increases in size for a period of perhaps one week; there- 
after it may remain stationary for a few days and then very gradually 
diminish in size. It commonly requires from two to four months for its 
complete disappearance. As it commences to diminish in size it loses its 
tenseness and becomes soft and flabby. 

Diagnosis. — The differential diagnosis from caput succedaneum should 
cause no embarrassment. In this latter condition the swelling of the scalp 
is not only present but is at its height at birth. It does not "fluctuate, is 
soft and flabby at all times, and begins to disappear on the second or third 
day. The differential diagnosis from hernia of the brain or its membranes 
presents no difficulties, as these symptom groups are quite distinct. From 
abscess of the scalp it may be differentiated by. the absence of inflamma- 
tion. If the tumor is red and tender and accompanied by constitutional 
symptoms the introduction under aseptic precautions of an aspirating 
needle will determine the character of the contained fluid. Rarely cephal- 
hematoma may be associated with a hemorrhagic diathesis resulting from 
some severe constitutional disorder. These are the only cases, and they 
are very rare, in which the prognosis may be unfavorable. 



98 BIRTH INJURIES 

Treatment. — As a rule no treatment is necessary; spontaneous recovery 
occurs. If there be delay in the disappearance of the tumor it may be 
wise to inquire whether or not the cephalhematoma has been converted by 
infection into an abscess. This may be determined by the introduction of 
an aspirating needle. In the event that pus is found the abscess is to be 
evacuated by free incision, thoroughly drained, packed with gauze, and 
thereafter treated as any other abscess. 

HEMATOMA OF THE STERNOCLEIDOMASTOID MUSCLE 

This condition results from the stretching and tearing of this muscle in 
such a way as to produce a hemorrhage into its sheath. This injury is 
comparatively rare, but occurs most commonly in breech presentations. 

Symptomatology. — Soon after birth it is noted that the child has a stiff 
neck. Its head is turned to the affected side. This torticollis results from 
contraction of the injured sternomastoid muscle, and within or along this 
tense muscle a small tumor may be felt. The part is painful to touch and 
the child cries when an attempt is made to overcome the deformity. After 
a time the hematoma is absorbed, but the contraction of the muscle may 
remain for many months and in some cases it is permanent. 

Treatment. — After some months, when all soreness and tenderness 
have disappeared, an attempt should be made to overcome the deformity by 
massage and passive movements. If these measures fail the patient should 
be referred to an orthopedic surgeon, that the deformity may be overcome 
by operative measures. 

BIRTH PALSIES 

Birth palsies may be central or peripheral in their origin. Central 
palsies are described under Cerebral Palsies. Peripheral or obstetrical 
palsies occur as two distinct clinical types, known as facial paralysis and 
upper arm paralysis. 

FACIAL PARALYSIS 

This is a paralysis of the seventh or facial nerve produced by injury 
during birth. It is commonly due to the pressure of the blades of the 
forceps. In most instances it is unilateral and the diagnosis is made by a 
lack of symmetry in the two sides of the face, due to paralysis of the 
muscles of one side. This is much more noticeable when the face muscles 
are in action. This condition is of little pathological importance, as the 
paralysis disappears spontaneously in two or three weeks. Very rarely the 
injury to the nerve may be so great that a permanent paralysis results. 

Treatment as a rule is unnecessary. In those cases, however, in which 
the paralysis persists the muscles should be exercised and atrophy delayed 
or prevented by the systematic use of massage and electricity as outlined 
under Cerebral Palsies. 



BIETH PALSIES 99 

UPPEE ARM PAKALYSIS 

(Duchenne-ErVs Palsy) 

* 

Etiology. — This is due to some injury of the fifth, sixth, and seventh 
cervical nerves during birth. It is more common after breech presenta- 
tions. It may be produced by pulling or twisting the arm or shoulder or 
by axillary pressure from a blunt hook or the obstetrician's finger. What- 
ever may be the modus operandi of the development of this paralysis, the 
fifth and sixth cervical nerves are so pressed upon, stretched, or twisted 
as to put them out of function, and a motor paralysis of the muscles which 
they supply results. The deltoid, biceps, brachialis anticus, and supinator 
longus muscles are most commonly involved. 

Symptomatology.- — As a rule only one arm is affected. It is noticed 
within two or three days after birth that this arm hangs limp and motion- 
less and is rotated inward. The paralysis in these cases is of the upper 
arm type described by Duchenne and Erb. The muscles of the wrist and 
hand are not affected. The paralysis is almost exclusively motor ; there is 
little or no disturbance of sensation. In the great majority of cases re- 
covery slowly takes place within two or three months. In a few cases the 
paralysis persists, the affected shoulder droops, muscular atrophy slowly 
takes place, and after a time the shoulder and upper arm are markedly 
lacking in development. With the wasting of the upper arm muscles there 
is also more or less lack of development of the bones, so that the arm is 
not only shriveled, but shorter than its fellow of the opposite side. Con- 
tractures of the muscles of the lower arm and hand develop. In rare 
instances subluxation of the head of the humerus takes place and greatly 
increases the deformity. In the worst cases the reaction of degeneration 
is finally followed by a failure to respond to either the galvanic or faradic 
current and the arm remains comparatively useless throughout life. 

Treatment. — Within two or three weeks after birth gentle but systematic 
massage should be begun. This is to be applied especially to the muscles of 
the shoulder and upper arm. If at the end of the third month conva- 
lescence has not been established, the faradic current should be used in 
connection with massage to exercise the paralyzed muscles, and in the 
event that the muscles do not respond readily or normally to the faradic 
current the galvanic current should be substituted. This treatment should 
be persisted in for months, and in the event contractures occur the advice 
of an orthopedic surgeon should be sought. Many of these cases are 
greatly benefited by surgical operations and by orthopedic appliances to 
overcome contractures and develop weak and degenerating muscles. 



SECTION III 

INFANT FEEDING 
CHAPTEE X 

MILK IN ITS EELATION TO INFANTILE NUTEITION 

Human breast milk is the ideal infant food, evolved by natural laws to 
suit the immature digestive organs of the human infant and to furnish the 
exact nutritional elements necessary for the rapid growth and development 
of the human organism. Its various ingredients, in their digestibility, 
their chemical composition, their total quantity, and in their relative pro- 
portion to other ingredients, are just what they should be; and if it were 
possible to feed every human infant upon normal human milk for the first 
nine months of its life the whole problem of infant feeding, which is the 
most important single subject claiming the attention of pediatricians to- 
day, would dwindle into comparative insignificance. 

Cow's milk is also an ideal food for the young of its kind, and its vari- 
ous ingredients, including their chemical composition, their digestibility, 
their quantity, and their relative proportion to other ingredients, are 
suited to the purposes cow's milk is intended 'to serve; namely, to furnish 
nutrition to the young calf and to develop its digestive organs so as to 
prepare them for the food which is to follow. Thus it is plainly evident 
that the breast milk of individual mammals is suited to the development 
of the young of its kind, but is not necessarily suited and has not been 
evolved by nature to nourish and develop the digestive organs of a different 
species. 

Milk is composed of fat, protein, carbohydrates, mineral salts, water, 
ferments, alexins, antitoxins, etc. It is a live fluid with definite chemical 
and biological properties which can only be understood by a careful chemi- 
cal and physiological study of its various ingredients in relation to infantile 
nutrition. 

Fat. — The fats which compose about 4 per cent, of both human 
and cow's milk are found in fat molecules suspended in the form of an 
emulsion. Their composition is very complicated. They contain neutral 
fats and fatty acids. The larger molecules contain a greater percentage 
of volatile fatty acids and the smaller ones more oleic acids, so that in 

100 ; 



FAT 101 

skimming milk, the larger fat globules rising to the surface above the 
smaller ones, a greater percentage of volatile fatty acids is skimmed oil! 
and more oleic acid left in the small globules. These fatty acids are 
mixed with glycerin and therefore occur in the form of glycerides. Butyric, 
palmitic, and stearic acids are the most important of the fatty acids. A 
small portion of the fatty acids are compounded with albumin in the form, 
of lecithin, which may exist outside of the fat molecule. Cow's milk con- 
tains a greater percentage of volatile fatty acids and a less percentage of 
oleic acid than human milk, and the fat in the former is in coarser emulsion 
and separates more easily than in human milk. This difference in the 
composition of the fats of the two milks may in part explain the fact that 
the human infant may digest and assimilate 4 per cent, of fat in woman's 
milk and yet fail to digest 2% per cent, of fat in cow's milk, and it may 
also explain why cow's milk, with its excess of volatile fatty acids, may 
predispose to acid intoxications in infancy, since these acids may be readily 
converted by hydrolysis into diacetic acid and acetone. 

In the natural food of the human infant fat is a most important agent 
in keeping up the heat and furnishing the energy for cellular work. It is 
the fuel of the cells and is furnished in large quantities because of the 
unusual cellular activity which occurs at this time of life. It is the most 
important factor in increasing the weight of the body during early infancy 
and is stored in large amounts in the subcutaneous tissues to serve emer- 
gency purposes. These storehouses are drawn upon when there is a fail- 
ure in fat digestion or fat assimilation. The nervous system which is so 
immature at birth and which develops so rapidly during the first year of 
life demands a large amount of fat for its proper development. The fat 
forms an important element of nerve structures, and there is no part of the 
infantile anatomy which suffers more seriously or more profoundly than 
does the nervous system when the digestion and assimilation of fats is 
interfered with. The bony structures also depend in part for their de- 
velopment upon a proper amount of fat in the tissues. The dangers from 
too little fat in the food are therefore most apparent, resulting in lack of 
development, especially in nervous and bony structures, loss of weight, 
anemia, and malnutrition. One should also remember that an excess of fat 
in the food of the infant may produce constipation or diarrhea with fat- 
stools and more or less serious gastrointestinal and nutritional disturbances ; 
the serious "food injuries" which result from an excess of fat are very 
uncommon except in those cases where both the fats and the sugars are 
given in excess at the same time. When the sugar percentage of a food is 
high an excess of fats is likely to cause more or less serious digestive disturb- 
ance and vice versa. It is, therefore, sometimes difficult to tell whether the 
child has been made ill by the fats or the sugars, since, as a rule, improve- 
ment follows the elimination of either the fats or sugars from the diet. 

Protein. — The chief proteins of milk are casein and lactalbumin; lacto- 
globulin, lactoprotein, and nuclein occur in smaller quantities. Under the 
term whey proteins all the proteins of milk except casein are grouped. In 



102 MILK IN RELATION TO INFANTILE NUTRITION 

woman's milk the whey proteins predominate over the casein in the pro- 
portion of 2 to 1, but in cow's milk the proportion is as 1 to 6. Chemistry 
has not as yet made any practical or important differentiation between the 
whey proteins of woman's and cow's milk, but we have in the quantities of 
casein and soluble albumins they contain two entirely different milks. The 
most important difference lies perhaps in the chemistry of the two caseins. 
This difference is recognized by the manner in which they react to the 
same ferments and reagents. In the stomach of the human infant the 
calcium casein of cow's milk (the form in which casein exists in cow's milk) 
is readily precipitated by rennet, in the presence of a slight amount of 
acid, into a clot of calcium paracasein, and later, as the hydrochloric acid 
is secreted in larger quantities, into hydrochlorate of paracasein and cal- 
cium; the calcium being separated from the paracasein clot by the hydro- 
chloric acid. This clot is larger and tougher than the clots which occur 
in the infant stomach from the action of the same reagents on human milk. 
In human milk the paracasein clots and the hydrochlorate of paracasein 
clots are soft and light as compared with those of cow's milk. 

Casein is rarely the cause of intestinal disturbance. On the other hand, 
Finkelstein and Meyer have apparently demonstrated that intestinal indi- 
gestion may be improved or controlled by increasing the quantity of the 
casein and diminishing the quantity of the sugar or fat in the milk. 
The digestibility of the casein of cow's milk depends largely upon the 
presence or absence of the conditions in the infantile stomach which cause 
its precipitation in small or large curds. It is very easily digested and 
assimilated if large clot formations can be prevented. If an alkali such as 
lime water or sodium bicarbonate, or an acid such as hydrochloric or lactic, 
be added to cow's milk before it enters the stomach, the alkali on the one 
hand or the acid on the other, by combining with the casein, may interfere 
with the action of the rennet in the formation of large clots, since rennet 
can only act in a slightly acid medium. The boiling of milk will also pre- 
vent the formation of large casein clots. In some instances it may also be 
necessary to reduce temporarily the amount of fat in the milk, so as to 
prevent its entanglement in the meshes of the clot. The danger, therefore, 
from an excess of protein lies in the fact that we are not always able to 
control the factors which cause clot formation, and for this reason it is 
sometimes necessary to diminish the amount of protein to a point where 
clot formation will not interfere with the intestinal digestion of the casein. 
In such instances it may be necessary to substitute the whey proteins in 
part for the casein so that the protein content of the food may not fall 
below the absolute nutritional demands of the body. In doing this, however, 
it should be remembered that in infants suffering from digestive disturb- 
ances the whey of cow's milk may aggravate the trouble. The human in- 
fant may digest the various food elements of cow's milk when they are held 
in the whey of human milk and may fail to digest them in the whey of 
cow's milk. 

The casein of cow's milk contains 53 per cent, of carbon, 15.65 per cent. 



CARBOHYDRATES 103 

of nitrogen, 7.06 per cent, of hydrogen and 0.85 per cent, of phosphorus, 
and 0.78 per cent, of sulphur. The general composition of proteins with 
the large per cent, of nitrogen they contain makes them absolutely neces- 
sary for cell growth and cell life. They furnish the material in large part 
from which the cells of the body are built up, and with the continuous 
cellular activity and nitrogenous waste there is a demand in the rapidly 
growing body of the infant for sufficient protein in the food not only to 
supply the cell waste, but to furnish material for the growth of new cells. 
The fats and carbohydrates, furnishing, as they do, the fuel from which the 
cells manufacture the heat and energy of the body, are necessary to prevent 
excessive nitrogenous waste, since the proteins are burnt up by the cells 
when the fats and carbohydrates are not present in sufficient quantity to 
supply them with fuel. This protection of the proteins by the fats and 
carbohydrates enables the cells to get on with the minimum amount of 
protein, a quantity sufficient to supply the normal nitrogenous waste and 
the material for new cells. The great loss that is sustained in protein food 
in the absence of fats and carbohydrates is indicated by the fact that twenty- 
two parts of protein are equal in fuel value to only ten parts of fat. It 
is very evident, therefore, that an artificial food should be carefully ad- 
justed in its various ingredients to furnish the cells with sufficient energy 
and heat-producing food so that the proteins may not be wasted in serving 
this purpose. If the food of the infant should contain too little protein 
or if the fats and carbohydrates are diminished to such a low percentage 
that a portion of the moderate amount of protein taken be used for fuel, 
in both instances we would have a protein starvation, resulting in anemia, 
malnutrition, and general enfeeblement of cellular activity in all parts of 
the body. 

Carbohydrates. — Human milk contains nearly 7 per cent, and cow's 
milk about 4 per cent, of milk sugar. This is the only carbohydrate that 
has been found in milk. There is little variation from day to day in the 
quantity of sugar in either woman's or cow's milk, this ingredient being 
subject to much less variation in quantity than the fats and proteins. 
Chemistry has not demonstrated any important difference in the compo- 
sition or reaction to digestive ferments of the sugar found in the milk of 
different mammals. The milk sugar in human milk is especially adapted 
to supply carbohydrate food to the young infant. It does not readily fer- 
ment and is quickly converted into dextrose in the intestines. On the other 
hand, the milk sugar of cow's milk is, according to the German school, 
the most common cause of intestinal fermentation. It appears that milk 
sugar, when held in the whey of cow's milk, is less rapidly absorbed and 
more subject to fermentation than is maltose or dextrin. The great ma- 
jority of normal infants, however, can readily digest it. 

The carbohydrates next to the albumins are the most important food of 
the infant. They, like the fats, serve as a fuel for the cells making heat, 
and, what is more important, furnish the food which supplies energy 
to the cells. In their heat-forming capacity they are second to the fats 



104 MILK m EELATION TO INFANTILE NUTEITION 

and in their energy-furnishing power they take the lead. It is an important 
physiological fact that the oxygen contained in carbohydrates is not only 
sufficient to oxidize their own hydrogen but to materially aid in oxidizing 
the waste products of the fat and protein molecules as they are broken down 
in the body, thus preventing an autointoxication. This is but an- 
other example of the interdependence of the protein, fat and carbohy- 
drate molecules in serving the nutritional demands of the body, and 
makes plain the fact that we are acting wisely when we imitate nature 
in making an infant food by combining these food elements in proper 
proportions. 

An excess of carbohydrates with other food elements (especially the 
fats) in normal proportions may result in diarrhea, loss of weight, fever, in- 
testinal irritation, and catarrh. An excess of carbohydrates with the other 
food elements below normal may result in anemia, rickets, and general 
malnutrition. A deficiency in carbohydrates with other food elements in 
excess will, as a rule, overtax the digestive capacity of the infant and 
thereby produce digestive disturbances. 

Inorganic Constituents of Milk. — Calcium, sodium, potassium, magne- 
sium, phosphorus and iron are the most important inorganic constituents of 
milk. All of these, excepting iron, are present in both human and cow's 
milk in sufficient quantities to meet the nutritional demands of the growing 
infant. 

Iron, as a necessary constituent of hemoglobin, is all-important in the 
oxidation processes which underlie body metabolism. The deficiency of 
iron in milk, which gradually increases as lactation proceeds, is made up 
during the first year of life from the stores of this mineral found in the 
liver and other organs of the newly born infant. At birth there is three 
times as much iron in proportion to body weight as in the adult. The 
partial iron starvation which occurs on a milk diet is not therefore of 
material consequence during the first year of life. But as the storehouses of 
iron become exhausted it is necessary to supplement the milk diet by such 
iron containing foods as eggs, fruit, and purees of vegetables, otherwise 
anemia and serious malnutrition may result. 

The other inorganic constituents of milk play a no less important role 
m the body metabolism of the human infant than does iron. All of these 
are found in such organic combinations in human milk that they are readily 
assimilated in sufficient quantities to meet nutritional demands. It is also 
true that the normal human infant can, as a rule, assimilate sufficient quan- 
tities of the inorganic constituents of cow's milk. The fact that a smaller 
percentage of the salts of cow's milk is assimilated is offset by the fact that 
they occur in larger quantities in cow's milk than in human milk. In cer- 
tain pathological conditions, however, the failure of the human infant to 
assimilate the salts of cow's milk produces serious disorders of nutrition 
and thereby becomes a factor in the production of marasmus and infantile 
atrophy. The common practice of adding lime water, sodium chlorid and 
other alkaline salts to cow's milk not only promotes the digestion and 



WATEE 105 

absorption of casein, but also facilitates the absorption of its mineral salts, 
especially calcium. 

The uses of mineral salts in the body are manifold. They are necessary 
for the growth and functional activity of all its cellular elements. They 
enter very largely into the construction of the bony framework which is 
growing so rapidly during the first year of life ; for this purpose large quan- 
tities of calcium and phosphorus are especially necessary. They maintain 
the normal irritability of nerve and muscle elements; in this function 
calcium plays the most important physiological role. A partial calcium and 
phosphorus starvation produces not only abnormalities in the bony frame- 
work, but greatly exaggerated irritability of nerves and muscles. The 
causes that lead to calcium starvation, however, are not always to be found 
in the food, since MacCallum and others have shown that a diminished 
secretion of the parathyroid glands may be a factor in its production. The 
mineral salts also maintain the osmotic pressure which determines the flow 
of water to and from the fixed tissue cells producing a shrinking of the 
tissues on the one hand or a swelling (edema) on the other. They also 
regulate the acidity or alkalinity of the body fluids, a most important func- 
tion, since upon the carefully adjusted reaction of the blood and other body 
media depends the normal functional activity of every cellular element 
in the body. 

The mineral salts and their combinations are an essential part of the 
food of the infant. They must be presented not only in proper relative 
proportions, but in such a form that they can be readily assimilated. These 
objects cannot be accomplished during the early months of life in any other 
way except by the feeding of milk, preferably human milk whose saline 
constituents are held in such organic combinations that they are readily 
assimilated. 

From the foregoing outline it is evident that all the food ingredients 
of milk are absolutely necessary to the health of the infant, and it is futile, 
therefore, to further discuss their relative importance. The normal infant 
has storehouses of protein, fat, carbohydrates, and salts always at hand, 
and has also a protective mechanism which enables it to substitute other 
materials for a time in case there be a partial starvation in any one of 
these food elements. But these storehouses may in time be exhausted and 
these protective mechanisms may fail, and then comes disaster to the infant 
in the form of some severe malnutrition, it matters not in which of the food 
elements there be a famine. 

Water. — About 68 per cent, of the infant's body is composed of water 
and about 87 per cent, of its natural food (milk) is water. These facts 
indicate the important role that water plays in the physiological processes 
necessary to maintain the health and life of the infant. An infant re- 
quires four or five times as much water in proportion to body weight as 
an adult. 

Water is the great solvent which brings into solution or suspension the 
food of the infant so as to present that food (the proteins, the carbohy- 



106 MILK IN RELATION TO INFANTILE NUTRITION 

drates, the fats, and the salts) in such a form that it can be readily cared 
for by the digestive organs. It carries the digested and assimilated food 
through the blood and lymph channels to every part of the body. This 
common carrier makes up about 78 per cent, of the blood and 96 per cent, 
of the lymph, and becomes the circulating media of the body, carrying the 
important elements of the blood and lymph to every cell in the body and 
carrying away from the cells to be excreted the waste materials of retro- 
grade tissue metamorphosis. This excretion of body waste prevents auto- 
intoxication and is effected by the elimination of the water carrying this 
waste through the kidneys, the intestines, the skin, and the lungs. The 
discharge through all these avenues of excretion is much more active in 
infancy than later in life ; this is especially true of the more active elimina- 
tion through the skin of the infant, which is fourfold greater than in the 
adult. Martin H. Fischer has emphasized the fact that water is practically 
the only diuretic and diaphoretic we have; all other agents supposed to 
act in these ways do so indirectly by bringing to the kidneys or skin free 
water ready for excretion. 

In the emergencies which disease produces nature takes advantage of 
these various channels for the rapid elimination of waste materials, and 
enormous quantities of poisonous fluids are carried off in a short time, 
especially through the skin and bowels. In these same emergencies the 
physician attempts to replenish the body fluids of the infant with pure 
water or physiological salt solution, so that vital processes may not suffer 
from the partial water famine which nature has created in her strenuous 
efforts to save the life of the child. Thus, in certain of these emergencies, 
water becomes a life-saver more important than food, stimulants, and all 
other agents. In the artificial feeding of infants an excess of water is not 
infrequently given. An infant should not be given more fluid than a 
breast-fed baby of the same age would obtain from its mother under normal 
conditions. Too much water in the food may cause dilatation of the stom- 
ach, indigestion, and consequent malnutrition. 

Digestive Ferments. — Human milk contains a diastatic ferment which 
transforms starch into maltose and dextrose. Becamp was the first to 
find this ferment; it has since been demonstrated by a number of ob- 
servers, and according to Spolverini may be developed in the milk of the 
cow and goat by feeding them on germinating barley. This would in- 
dicate that there is an important physiological purpose served by this fer- 
ment in the young human infant which is met in some other way in the 
young of the cow and the goat. The purpose served is perhaps to supple- 
ment the feeble digestive power for starch in the young human infant, and 
as the starch digestive capacity of the young of the cow and goat is greater 
it is not necessary to provide this ferment in their milk. 

Lipase is a fat-splitting ferment which breaks down neutral fats into 
fatty acids and glycerin. It was isolated by Lussatti and Biolchini and is 
much more active in human than in cow's milk. This active fat-splitting 
ferment in human milk may account in part for the fact that young 



ALEXINS 107 

infants are capable of digesting and assimilating much larger quantities 
of the fat of human milk than of cow's milk. 

Arguing by analogy, one would think that nature, in developing a fat- 
splitting and a starch-digesting ferment in woman's milk, would also have 
developed a protein-digesting ferment, and this is very probably the case, 
although experimental evidence is not as yet sufficient to put this question 
beyond a doubt. Spolverini demonstrated the action of ferments which 
resembled the action of trypsin and pepsin, but Benoit could not agree with 
him. 

Alexins. — Alexins are substances which have a bactericidal and globuli- 
cidal action. They are found in human milk in sufficient quantities to 
make it decidedly destructive to bacteria and other foreign cells. They 
are perhaps derived in part from both the serum of the blood and from 
the cells of the mammary gland. This property of human milk is perhaps 
one of the most important safeguards which the young breast-fed infant 
has against gastrointestinal diseases. The microorganisms, which are con- 
stantly being put into their mouths, on foreign objects, rarely produce any 
serious intestinal disturbance. It is also true that artificially fed infants 
when suffering from gastroenteritis will, as a rule, quickly recover when 
given breast milk, and it is probable that the bactericidal action of the 
milk is one of the factors that contributes to this 'result. The alexins 
are not absorbed in sufficient quantities from the milk to give to the blood 
and other body fluids of the infant any marked bactericidal qualities, so 
that the comparative immunity which breast-fed infants enjoy from certain 
acute infectious diseases is perhaps due to other substances, which pass 
from the mother through the breast milk to the infant, such as antitoxins, 
agglutinins, and other antibodies. The immunity, either natural or ac- 
quired, which the mother or Wet nurse has for certain infectious diseases 
is, in part at least, transferred to the nursing infant. The substances which 
confer that immunity are transferred through the milk to the infant. It 
follows therefore that the nursing infants are partially immune from those 
infections onlv to which their wet nurse is immune. 



CHAPTEE XI 
HUMAN BEEAST MILK IN ITS EELATIONS TO INFANT FEEDING 

COMPOSITION OP COLOSTRUM AND HUMAN MILK 

Colostrum is the secretion of the human breasts which immediately 
precedes the formation of breast milk. About the fourth month of preg- 
nancy the breasts commence to secrete in scanty amounts a yellowish, 
sticky fluid called colostrum. This secretion, which can be squeezed out 
of the breasts in slightly increasing quantities from this time until the 
birth of the child, is present in sufficient quantities during the first few 
days after birth to act as a laxative and serve nutritional purposes. 



108 MILK IN ITS RELATIONS TO INFANT FEEDING 

Colostrum differs from normal milk in its physical and chemical prop- 
erties. It is more alkaline in reaction, more yellow in color, is not so sweet, 
and has a higher specific gravity, 1.040. It is richer in fat and soluble 
proteins and poorer in casein. Under the microscope it shows peculiar 
large characteristic corpuscles which are filled with fat globules of varying 
sizes. On the removal of this fat by ether the corpuscle shows a large 
nucleus. These corpuscles are from five to ten times the size of the human 
blood corpuscle. Leukocytes and pavement epithelium are also present in 
addition to a large number of fat globules similar in size to those found 
in normal human milk. The composition of colostrum is shown in the 
following table from Camerer and Soldner : 

Water 86.70 

Proteins 3.07 

Fat 3.34 

Milk sugar 5.27 

Ash ■ 0.40 

Under the stimulus of nursing the colostrum gradually gives way to 
the normal milk secretion, which may be established as early as the third 
day, but is sometimes more or less delayed until the fifth or sixth day. 





Fig. 17. — Colostrum. 



Fig. 18. — Woman's Milk. 



Human milk is a bluish white, sweet fluid which, as shown by Kerley 
and others, is faintly acid to phenolphthalein, but is amphoteric or neutral 
to litmus paper. Its specific gravity varies from 1.027 to 1.035. Micro- 
scopically the fat globules, which vary in size from that of a red to a 
white blood corpuscle, are held in more or less satisfactory emulsion. 
Epithelial cells, colostrum and pus corpuscles which are occasionally found 
are to be regarded as foreign elements and as indications pointing to the 
deterioration or contamination of the milk. 



HOW TO DETERMINE WHOLESOMENESS OF MILK 109 



HOW TO DETERMINE THE WHOLESOMENESS OF MILK 

The fundamental characteristics which differentiate the milk of differ- 
ent species were dwelt upon in the previous chapter, and in these important 
facts we learn why it is so necessary to the nutritional demands of the 
infant that it should have all the breast milk it can possibly get under the 
existing circumstances. This principle in infant feeding is all-important 
since about two-thirds of the mothers of our land are unable to furnish 
their infants with a milk, which in quantity and quality is equal to the 
nutritional demands of the first nine months of life. Among the wealthy 
class it is rather unusual to find a mother who can supply breast milk to 
meet the demands of her infant. Among the poor the woman has to work 
the greater portion of the day in unhygienic surroundings, live on improper 
and perhaps insufficient food and be separated from her infant many hours 
at a time, which interferes with her furnishing normal milk at proper 
intervals throughout the full period of lactation. It is largely, therefore, 
among the middle class that we find women who are not only willing but 
who are physically able to fully nourish their infants for a proper length 
of time. In America, perhaps more than in other countries, the social 
conditions are unfavorable to the production of mothers capable of per- 
forming this most important function. At any rate, we are led to infer 
from published observations that supplemental and full artificial feeding 
are perhaps more commonly necessary in this country than in some Euro- 
pean countries. 

In approaching the subject of breast-feeding it is important that the 
physician should understand that there are ofttimes abnormal variations in 
the quantity and composition of an otherwise good milk, which may make it 
temporarily insufficient or unwholesome for the infant. It is plainly evident 
therefore that it would be worse than folly for the physician to infer that 
such a milk was not suited to the nutritional demands of the individual 
infant until a more or less prolonged trial of the milk, its chemical compo- 
sition or the conditions under which it is produced have demonstrated that 
it is an unsuitable food. The physician should have in mind certain facts 
which will help him in determining the wholesomeness of an individual 
breast milk in its relation to the nutritional demands of an individual 
infant, and along these lines the following observations are important : 

1. If a breast-fed baby is well nourished and gaining in weight, all 
indications pointing to the unwholesomeness of its food, such as colic and 
indigestion, are of minor importance and suggest not that the breast milk 
be discontinued, but that it be modified by regulating the diet and general 
hygiene of the mother. 

2. If a breast-fed baby is poorly nourished and losing in weight, with 
no evidence on the part of the infant that the milk is producing gastro- 
intestinal disturbance, the indications are not that the breast milk should 
be discontinued, but that it be supplemented by artificial feeding at each 



110 MILK IN ITS RELATIONS TO INFANT FEEDING 

nursing and an effort made to increase the quantity and quality of the 
mother's milk by proper food and hygiene. 

3. A poorly nourished breast-fed baby, losing in weight and suffering 
from chronic indigestion both on breast and mixed feedings, should be 
weaned or provided with another wet nurse. In these comparatively rare 
cases the individual breast milk is at fault even though chemistry may fail 
to find the defect. 

If the question arises as to whether a mother's milk is a suitable food 
for the infant, the infant itself under the three fundamental rules above 
given is the best answer to this question. As supplemental evidence, how- 
ever, an examination of the breast milk may be made to determine its quan- 
tity and also the relative and absolute quantity of its various ingredients. 
The quantity of the breast milk may be determined by weighing the baby 
before and after each nursing, and for practical purposes it may be assumed 
that an increase of an ounce in weight indicates that a fluid ounce of milk 
has been taken; that is to say, if the infant weighs five ounces more after 
a nursing it has taken five fluid ounces of milk; and it may also be as- 
sumed, for practical purposes, that infants between one and seven months 
of age should take in the average at each nursing one ounce more than 
they are months old. Holt gives the following table of the daily average 
quantity of milk taken by normal infants at different ages : 

At the end of the 1st week 10 to 16 oz. (300 to 500 gm.) 

During the 2d week 13 to 18 oz. (400 to 550 gm.) 

During the 3d week 14 to 24 oz. (430 to 720 gm.) 

During the 4th week 16 to 26 oz. (500 to 800 gm.) 

From the 5th to the 13th week 20 to 34 oz. (600 to 1,030 gm.) 

From the 4th to the 6th month 24 to 38 oz. (720 to 1,150 gm.) 

From the 6th to the 9th month 30 to 40 oz. (900 to 1,200 gm.) 

The quality of the milk with reference to the amount of its various 
ingredients may be determined by a chemical analysis, but as the variations, 
especially in the fats and proteins, from day to day are very marked, it is 
generally necessary to make repeated examinations of the milk to arrive 
at its average composition. Milk analyses, therefore, because of their un- 
reliability and the expense of making them, are not of sufficient practical 
value to warrant their use as a routine measure. In a breast-fed baby, 
suffering from well-marked scurvy, a professional chemist reported to me 
that the breast milk was absolutely normal. A change, however, to cow's 
milk in this case brought about a rapid cure. Simpler and less accurate 
methods for examining breast milk are used and the approximate results 
thus obtained may be of some value. For this purpose the physician may 
use Holt's apparatus, made by Eimer & Amend, of New York. Full 
directions for its use accompany each set of apparatus. 

Holt gives the following table as the average composition of human 
breast milk: 



HOW TO MODIFY QUANTITY AND QUALITY OF MILK 111 

Average Common Healthy 

per cent. variations per cent. 

Fat 4.00 3.00 to 5.00 

Sugar 7.00 6.00 to 7.00 

Proteins 1 . 50 1 .00 to 2 . 25 

Salts . 20 . 18 to 0.25 

Water 87.30 89 . 82 to 85 . 50 



100.00 100.00 100.00 

The sample of milk used for analysis should be a part of all the milk 
that can be taken from the breast. The physiological stimulus of sucking 
is not given by the breast pump, and the milk drawn in this way is there- 
fore usually low in fat and protein. The usual examination of breast milk 
made from small samples drawn by the pump are misleading because they 
do not represent the same quality of milk which the infant receives from 
the breast. 

HOW TO MODIFY THE QUANTITY AND QUALITY OF MILK 

In modifying human milk to suit the nutritional demands and diges- 
tive capacity of the infant it is most important that the general health 
of the mother should be carefully looked after. She should take a mod- 
erate amount of exercise in the open air, have sufficient sleep and rest and 
not be harassed by unnecessary petty household details, and above all the 
quantity and quality of her food should be carefully supervised to avoid 
gastrointestinal disturbance. She should eat a moderate quantity of fruits, 
vegetables, farinaceous and nitrogenous food, being always careful that 
the food selected is easily within her digestive capacity. Overeating, eating 
at irregular hours, drinking more than a very moderate amount of alcoholic 
stimulants and taking highly seasoned dishes, salads and foods difficult of 
digestion are to be carefully avoided. Constipation, when it exists, should 
be overcome by proper medicines and diet. 

The quantity of the milk may be increased by improving the general 
health of the mother, by massage of the breasts and by certain foods, such 
as milk, gruels and the liquid malt extracts. The fat may be increased by 
meats, eggs, milk and the liquid malt extracts, and may be diminished by 
diminishing the quantity of these foods and substituting fruits, vegetables, 
bread and cereals. The proteins may be increased by rest and by giving an 
increased quantity of meat and eggs, and they may be lowered by exercise in 
the open air and by a diminished quantity of meat and eggs. 

Menstruation, especially in neurotic mothers, may so change the char- 
acter of the milk as to produce slight gastrointestinal indigestion, but these 
disturbances are rarely of enough importance to justify corrective measures 
of any kind. 

Nervous impressions produced by great excitement, grief and fright 
may produce temporary changes in the breast milk sufficient to cause colic 
and indigestion in the infant, and prolonged nervous strain and worry 
9 



112 BREAST FEEDING 

may be a very serious factor in diminishing the quantity and quality of the 
breast milk. 

Arsenic, salicylic acid, alcohol, iodin, belladonna, opium, salts, iodids, 
bromids, cascara and senna when taken, may be eliminated through the milk 
in sufficient quantities to produce gastrointestinal indigestion or toxemia in 
the nursing infant. 

Bacteria are occasionally eliminated in the milk, but the danger from 
this source is exceedingly slight. Tubercle bacilli, typhoid bacilli and 
streptococci are, however, sometimes found in the breast milk of mothers 
suffering from the constitutional diseases which these microorganisms 
produce. The acute infectious diseases when prolonged and severe, such as 
typhoid fever and scarlet fever, contraindicate nursing, not only because of 
the danger of infection to the child, but because of the depletion of the 
mother. Other less severe infections, such as measles, influenza and even 
diphtheria unless it be very severe, should not interrupt nursing. In these 
conditions if proper precautions are taken the infant, as a rule, escapes 
the disease, or, if not, contracts it in a very mild form from being partially 
protected by the antibodies which are eliminated through the milk, and the 
dangers thus incurred are much less than those incurred by weaning the 
young infant. 

A syphilitic infant should not be permitted to nurse a nonsyphilitic wet 
nurse any more than a syphilitic wet nurse should be allowed to nurse a non- 
syphilitic infant ; in both instances the disease may be transferred. A con- 
genially syphilitic infant, however, may nurse its mother without danger 
of communicating the disease. 

Active tuberculosis in the mother is an absolute contraindication to 
nursing. Mothers, however, who have recovered from active tuberculosis 
may under urgent conditions be allowed to nurse their offspring. The 
danger here, however, is rather to the mother than to the child, inasmuch 
as the drain upon her may so weaken her powers of resistance that a latent 
tuberculosis may develop into an active one. 

General debility, malnutrition and pronounced anemia on the part of 
the mother, as a rule, contraindicate nursing unless the condition be a 
temporary one that can be readily removed by good hygiene and medication. 



CHAPTER XII 

BEEAST FEEDING 

NORMAL BREAST FEEDING 

It is a well-recognized fact that in healthy mothers the regular and 
vigorous nursing of the breasts by an infant strong enough to nurse is 
the most important single factor in stimulating the secreting glands of 
the breast to perform their normal physiological function; that is, to supply 



NORMAL BREAST FEEDING 113 

an abundant quantity of normal milk. As Budin says, "the quantity of the 
milk varies with the demand." In the strong and vigorous under the 
stimulus of regular nursings the breast can in many instances be made 
to secrete sufficient milk to nourish two infants. The physician should 
therefore direct that the infant be put to the breast within four or five 
hours after birth, and during the first three days it is induced to nurse 
as vigorously as possible at intervals of four to six hours, dependent upon 
the condition of the mother. For three days even after a normal labor 
the mother is the prime consideration. It is most important that she should 
have proper rest and sleep undisturbed by regular nursings or by the care 
of her baby. The nursings during this time promote uterine contractions, 
clear the breasts of colostrum and hasten the establishment of the normal 
milk secretion on the third or fourth day of nursing. During these first 
days it is important that the infant should be given water to drink, either 
in the form of pure water, a milk-sugar solution, toast water, or a very weak 
solution of cow's milk, one of water to five of milk. A few teaspoonfuls of 
one of these mixtures given at intervals during the day will prevent loss 
of weight and furnish water for washing out the gastrointestinal canal, the 
kidneys, and other excretory organs. If the milk secretion is not estab- 
lished by the third day the milk mixture may be given in larger quantities 
until the delayed milk secretion is established. After the third or fourth 
day, with the mother thoroughly convalescent, regular nursings should 
be commenced. The baby should then be nursed every two hours from seven 
A. M. to nine P. M., and during the night should never be awakened for a 
feeding or put to the breast oftener than every four hours. In putting the 
infant to the breast the nipple should be worked out so that the child can 
get a firm grasp on the entire nipple. It should be allowed to nurse in 
the average fifteen minutes. Where the milk supply, however, is insufficient 
the time may be prolonged to twenty minutes, but during this time the 
child should not be allowed to lie with the nipple in its mouth, but should 
be kept nursing. When the baby is removed from the breast the nipple 
should be cleansed with water or boracic acid solution, and if there be any 
tenderness about the nipple it should be washed in a 50 per cent, alcohol 
solution and dusted with dermatol to harden and heal it. If there be ero- 
sions or fissures about the nipple these should be treated after each nursing 
with a 1 or 2 per cent, solution of nitrate of silver and the baby for a time be 
made to nurse through a nipple shield. Any disease of the nipple should 
receive prompt and careful treatment, as it may lead to caking of the 
breast, mastitis, or even abscess. The latter would be not only painful 
and interfere with the general health of the mother, but would cause the 
permanent loss of that breast to the infant. When, therefore, one of the 
breasts becomes swollen, hard and tender, accompanied possibly by fever, the 
baby should not be allowed to nurse from that breast until the inflammatory 
conditions have subsided, and the mother should be confined to bed for a 
few days with hot compresses of 20 per cent, alcohol, boracic acid, or some 
other antiseptic held over the breast in such a manner as to lift and support 



114 



BKEAST FEEDING 



it. During this time a breast pump may be used from time to time to 
relieve the engorgement, and under this treatment convalescence, as a rule, 
quickly results, the breast is restored to its normal condition, and the baby 
may again be allowed to nurse both breasts. In the event that such an 
emergency temporarily diminishes the milk supply of the infant so that it 
is insufficiently nourished it may be given, following every other nursing, a 
sufficient quantity of modified milk to make up the deficiency. 



25 



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12342678910 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 
AGE IN WEEKS 

Fig. 19. — Weight Chart of Breast-fed Infant. 

The intervals between the feedings are increased to two and a half 
hours when the infant is two months old, to three hours when it is four 
months old, and to four hours when it is nine months old, and during all 
of this time the baby must be fed at regular intervals, awakened on the 
stroke of the clock during the day and made to go as long as possible with- 
out nursing between ten in the evening and six in the morning. From the 
third to the fifth month one nursing at night should be sufficient, and as 
soon after the fifth month as possible the baby should be trained to go 
without nursing from ten at night until six in the morning. It is re- 
markable how a normal baby fed on normal milk will adapt itself to the 
regular hours of nursing, and in such infants the question of sleeping 
through the night is absolutely a matter of training. In a baby eight or 
nine months of age, trained to sleep the night through, the habit becomes 
so firmly fixed that it is rarely disturbed even by illness. 



MIXED FEEDING 

When it has been determined that the breast milk is insufficient, mixed 
feedings should be resorted to ; that is to say, the infant is to be given the 
breast at regular intervals, followed at every feeding by a sufficient quantity 
of modified milk to make up the deficiency. The success of this method of 



MIXED FEEDING 115 

feeding depends upon the following facts: First, frequent nursings will 
stimulate the secretion of milk and give the baby all the breast milk it can 
possibly obtain. Second, supplementing every nursing with the bottle, 
instead of nursing at one time and giving the bottle at another, insures suffi- 
cient nourishment at regular intervals, as the infant has the option of 
emptying the bottle or not after every nursing; while by the alternate 
nursing method, breast at one time and bottle at another, it may be a 
question with the infant of a feast and a famine. If the breast milk is 
insufficient it would be starved at alternate feedings. Third, and perhaps 
more important than all, is the fact that cow's milk is more easily digested 
when it is mixed in the stomach of the infant with breast milk. This is 
perhaps due to the more active ferments in human milk, which assist in the 
digestion of the starches, fat and proteins of cow's milk. At any rate, it is 
a fact which clinical experience has amply demonstrated that cow's milk 
is more easily cared for by the infantile digestive organs when it is mixed 
with human milk. The importance of mixed feeding has never been fully 
appreciated by the medical profession, and of all countries America is the 
one in which mixed feeding should be insisted upon, because here more than 
in European countries are we called upon to supplement mother's milk by 
artificial food. Mixed feeding, therefore, in the sense here outlined, is one 
of the most valuable expedients we have for getting good nutritional results 
in the feeding of infants. 

Before dismissing the subject of mixed feeding I wish also to speak 
of the value of this method among the poor, where, because of their loca- 
tion and surroundings, they have to depend upon artificial infant foods 
to supplement nursing during the summer months. During these hot 
months these artificial foods, such as condensed milk, malted milk and 
Nestle's food, are life-savers to this class of our population. It is absolutely 
impossible for city authorities to arrange that the poor of the city shall 
have the proper medical attention, and be furnished with a clean and prop- 
erly modified milk, with the facilities for caring for the same. All of these 
things are absolutely necessary to insure the success of artificial feeding 
with modified milk. It becomes necessary therefore for the poor of our 
cities, in the vast majority of instances where the breast milk is insufficient, 
to resort to cheap, easily prepared and easily cared for artificial foods to 
supplement the breast feedings. In such instances and under such condi- 
tions it is to be strongly recommended that these artificial foods should 
follow the breast feedings. The breast milk in this form of artificial feed- 
ing will in large part prevent the scurvy, rickets, and other malnutritions 
that commonly follow the long-continued exclusive use of these proprietary 
foods. This method of mixed feeding with proprietary foods has been suc- 
cessful in my hands; I have utilized it in my dispensary work, and oft- 
times in my private practice, where the conditions were such that modified 
milk could not be safely used. 



116 BEEAST FEEDING 

WEANING 

The question of weaning an infant is altogether an individual one, de- 
pending upon the individual conditions which one has to face in each in- 
stance. On general principles, however, it may be stated that the infant 
from birth should be accustomed to taking a little water in addition to 
breast milk, not that this water is necessary after the milk secretion is 
established, but that it is a good thing to accustom the baby to taking some 
other fluid than breast milk and to take it in a different way, either from 
the spoon or from a bottle. This, as a rule, obviates the difficulty which is 
occasionally encountered of starving the baby into taking artificial food. 
It is also a good practice even in perfectly nourished breast-fed babies, 
after the third or fourth month, to give them one bottle of modified milk 
as a substitute for one nursing in the twenty-four hours. This serves the 
double purpose of educating the infantile digestive organs to the digestion 
of cow's milk and of giving the nursing mother the opportunity of getting 
away from home and its duties for a brief period during the day. This 
relieves the mother of a certain amount of nervous strain and promotes 
her health and strength. 

As time goes on in a perfectly normal breast-fed baby the number of 
modified milk feedings is to be increased, so that at eight or nine months 
the child is to have at least two feedings of modified milk in twenty-four 
hours. Within the next three months the number of feedings of modified 
milk is gradually increased until the infant at one year of age is weaned. 
The time of weaning, however, even in a normal child, may vary with the 
season of the year and with the health of the mother. If the birthday of 
the child comes during the hot months of summer it may perhaps be well 
to continue to give the child a few feedings of breast milk each day until 
it is thirteen or fourteen months of age, as this would enable the physician 
to utilize the breast milk in the emergency of any acute illness on the part 
of the gastrointestinal canal. In any event, whatever the conditions may 
be, it is much better, if possible, to wean the child gradually, letting it have 
the advantage of all the breast milk it can get for the first seven or eight 
months, and then during the next four months slowly educate its diges- 
tive organs to the digestion of cow's milk. Sudden weaning is justified only 
where acute conditions of ill health on the part of the mother make it abso- 
lutely necessary. Weaning during the hot months of summer is to be 
avoided if possible, and this is perhaps always possible under the method of 
mixed feeding outlined above. It is, of course, not always possible to solely 
consider the interests of the infant as to the time of weaning. The mother's 
health may demand that the child be weaned as early as the second, third 
or fourth months, but in such instances the method of mixed feeding given 
above should be used. 



THE WET NURSE 117 



THE WET NURSE 



The conditions in America are such that the wet nurse is not as com- 
monly used for breast-feeding the infant as in Europe. This is because 
the class of women who are willing to undertake this service are morally 
and physically of a much lower type, and yet it is possible to secure a more 
or less satisfactory wet nurse when the emergency arises which demands 
one. The wet nurse may be necessary to start the infant when the mother's 
milk cannot be used. This is especially true in premature infants or in 
malnourished infants born of tuberculous or otherwise diseased parents. 
It is also sometimes absolutely necessary following acute gastrointestinal 
diseases in the bottle-fed infant when other foods cannot be found upon 
which the infant can thrive. The physician must always bear in mind that 
a premature or malnourished infant that is doing badly under artificial 
feeding will probably continue to grow worse in spite of changes in arti- 
ficial foods, and that such an infant may be expected to improve under good 
wet nursing. Wet nursing is to be preferred to artificial feeding in every 
such instance. Our knowledge of artificial feeding, however, has been so 
much improved of late that in the great majority of instances an infant 
can be successfully fed, supplying all its nutritional demands. This fact, 
together with the fact that satisfactory wet nurses are difficult to find and 
that they are undesirable members of a household, decides the mother in 
most instances to undertake the slight additional risk of artificially feeding 
her infant rather than undergo the expense and suffer the annoyance which 
the installation of a wet nurse would entail. It is therefore the important 
duty of the physician to determine in individual cases when a wet nurse is 
necessary. 

Selection of a Wet Nurse. — A wet nurse must be free from all signs of 
tuberculosis, syphilis, and other chronic diseases. She should be in good 
physical condition, presenting the appearance of a woman capable of sup- 
plying sufficient milk to an' infant without injury to her own health. She 
should also be comparatively young, preferably a primipara, and her baby 
should be over one month and less than seven months of age. Her own 
infant is the best indication of her fitness for wet nursing; it should show 
by its physical development that it has obtained a sufficient quantity of 
breast milk to supply its nutritional demands. There must also be a dis- 
tinct understanding with the wet nurse before she is employed that she 
will conform to the rules of diet and hygiene necessary to produce the best 
results in furnishing a milk suitable to the nutritional demands of the infant 
she is to serve. 



118 AKTIFICIAL FEEDING OF INFANTS 

CHAPTEE XIII 
FOOD MATEKIALS USED IN THE ARTIFICIAL FEEDING OF INFANTS 

COW'S MILK 

Fresh Cow's Milk. — Cow's milk is the food almost universally recom- 
mended for the artificial feeding of infants. 

The most important property of good cow's milk is cleanliness. There 
is little or no difficulty in obtaining clean milk in the country and in small 
towns, provided the ordinary rules of stable hygiene and personal cleanli- 
ness in the handling of the milk are observed. In large cities the problem 
is a very different one, since the milk has to be transported long distances, 
pass through many hands and the time between the milking and the con- 
sumption of the milk is greatly increased. 

The great superiority of clean raw milk as an infant food over all other 
artificial foods has been so universally recognized in recent years that all 
of our large cities have made most strenuous efforts to obtain clean raw 
milk. The pioneer methods employed by the Walker-Gordon laboratories 
under the advice of Rotch, and the successful movement of Coit by which he 
was able to put upon the market a clean milk under the name of "certified 
milk/' are largely responsible for the methods now employed in furnishing 
clean milk to our large cities. These movements have resulted in the es- 
tablishment of model dairy farms so located that the rapid transportation 
of milk from the country to the city is possible. In the management of 
these farms the following conditions are necessary: — The cows must be 
healthy and free especially from tuberculosis; the stables must be clean 
and well ventilated and the barnyards free from manure and kept in as 
sanitary a condition as possible; the water supply used for dairy purposes 
should be pure ; the food of the cows should be free from ensilage, strongly 
flavored weeds and distillery and brewery slops. The cows should be kept 
clean by daily grooming and the milking should be done with clean hands 
from clean udders into clean pails, using every precaution to prevent the 
early contamination of the milk. The first few strains of milk from each 
udder should be discarded. The milk should be immediately removed to 
a separate building, where it is rapidly cooled, bottled, and then placed in 
a refrigerator until it starts on its journey to the city. In the carrying 
of the milk to its destination it should be kept cool and should reach the 
consumer with a bacterial content not above 10,000 to the c. c. Milk fur- 
nished under these conditions may be fed in a raw state with safety to the 
infant. 

The health boards and medical societies of our cities, following the 
initiative of Coit, have selected a board of chemists and bacteriologists 
whose duty it is to make frequent examinations of this milk as it is de- 
livered to the consumer. These examinations determine the bacterial con- 



COW'S MILK 119 

tent of the milk, the amount of butter fat it contains, the relative per- 
centage of its various ingredients, and the presence or absence of chemical 
preservatives and other foreign matter. When the milk of the individual 
dealer always conforms to the standards set by the medical boards he is 
furnished with labels containing the words "certified milk/' These labels 
when placed upon the bottles are a guarantee to the consumer that the con- 
tained milk conforms in all respects to the standards laid down by the 
medical authorities. 

The "certified milk" which is sold in nearly all of our large cities con- 
forms to the following standards : First, freedom from pathogenic bacteria ; 
second, a bacterial content not exceeding 10,000 to the c. c. ; third, freedom 
from dirt and other foreign organic matter ; fourth, freedom from chemical 
preservatives ; fifth, a constant nutritive value with about 4 per cent, of fat 
and a proper percentage of proteins and carbohydrates. 

It is plainly evident that milk of this character constantly supervised 
by competent chemists and bacteriologists is a great boon to every large 
city, but it is also evident that the production of this class of milk requires 
an unusual outlay of money on the part of the dairymen and must there- 
fore be sold at a price that is absolutely prohibitive to the poor of our cities. 
For this reason in most of our large cities a second grade of milk is fur- 
nished by the same dairies and under the supervision of the same board 
of milk inspectors. The commercial name of this milk is "inspected milk" 
and it bears such a label testifying to its relative cleanliness. "Inspected 
milk" differs from "certified milk" chiefly in the standards required for its 
bacterial content. During the winter months it must not contain more 
than 60,000 bacteria to the c. c, and during the summer months not more 
than 100,000 to the c. c. In other bacteriological and chemical standards 
it is on the same plane as "certified milk," and sells a few cents cheaper 
by the quart. 

Sterilized Milk. — But notwithstanding the efforts of health boards and 
medical societies it is impossible to put upon the market in large cities a 
clean milk at a price within the reach of the poor. The "certified and in- 
spected milks" can be utilized only in the feeding of a comparatively small 
percentage of the infant population of our large cities. For this reason 
sterilization and pasteurization of milk still remain most important life- 
saving measures in the feeding of infants during the summer months, when, 
because of the heat, milk contamination increases rapidly. It must be re- 
membered, however, that unclean milk — that is, milk that contains a large 
number of microorganisms — has undergone fermentative changes which 
injure its nutritive value and which may have produced poisonous, irritating 
bodies which make it a dangerous food for infants. Milk thus contaminated 
cannot be made wholesome by sterilization, so that when pasteurization or 
sterilization are resorted to as a means of preventing further bacterial con- 
tamination it is necessary to start with as clean a milk as possible. 

Cow's milk may be sterilized by heating to 212° F., or 100° C, for 
twenty minutes. This produces what is ordinarily termed sterilized milk. 



120 AETIFICIAL FEEDING OF INFANTS 

The heat destroys all the developed bacteria, but does not destroy the spores, 
and the milk is therefore not absolutely sterile, since these spores, after a 
time, may develop bacteria. The sporulated bacteria, however, are not of 
enough importance to justify the further application of heat. Sterilization 
of milk may be accomplished by means of the Arnold Steam Sterilizer, or by 
placing the milk bottles in boiling water for twenty minutes. The latter 
process is of great practical value among the poor of our large cities be- 
cause of its simplicity and cheapness. 

The advantages derived from sterilizing milk are as follows : It results 
in a loss of acidity on the part of the milk, which causes a retardation in 
rennin coagulation and thereby causes the casein to be precipitated in finer 
flakes so that it is more readily acted upon by digestive ferments; large 
casein curds never form in this milk. The fermentative processes are 
stopped and the milk is not further contaminated by bacteria. This is the 
prime object in the sterilization of milk, and greatly reduces the dangers 
of milk poisoning. Sterilization is the cheapest way of preserving milk. 
In fact, it is the only practical way by which it may be kept wholesome 
for use among the children of the poor in our large cities. These people 
cannot afford and cannot care for clean, raw milk. So with them the only 
available safe substitute in hot weather for condensed milk and the patent 
milk foods is sterilized milk. With infants capable of digesting sterilized 
milk it serves nutritional purposes much better than proprietary foods. 

The disadvantages which are said to result from sterilizing milk are 
as follows: Decomposition of nuclein; separation of phosphorus from its 
organic union; partial coagulation of soluble proteins; partial destruction 
of the fat emulsion; increased difficulty in the digestion of casein; partial 
precipitation of citric acid as an insoluble calcium citrate; partial conver- 
sion of milk sugar into caramel; partial separation of the lime salts from 
their combination with calcium, thereby rendering them less easily ab- 
sorbed; partial loss of carbonic acid, oxygen and nitrogen, which are ex- 
pelled by heating; complete destruction of ferments, alexins, agglutinins 
and other live principles in the milk. These changes represent a distinct 
nutritional loss to the infant in that the important ingredients of the milk 
are rendered somewhat less digestible and assimilable. Sterilized milk also 
has a tendency to produce constipation with its resultant intestinal intoxi- 
cations. 

Pasteurized Milk.— When the medical profession awoke to the disad- 
vantages of sterilized milk it began to experiment with lower temperatures, 
hoping in that way to destroy the developed bacteria without producing im- 
portant chemical and biological changes in the milk. Koplik suggested the 
heating of milk for infant feeding at a lower temperature and Monti rec- 
ommended a temperature of 180° F., and this process, in contradistinction 
to sterilization, was called pasteurization. Freeman has done very valuable 
work in popularizing a still lower temperature of pasteurizing which kills 
the greater portion of the developed bacteria and yet produces no serious 
chemical or biological changes in the milk. This process is very generally 



COW'S MILK 



121 



used in this country, especially in our large cities during the summer 
months, and when properly used is a most important life-saving measure. 

The Freeman Pasteurizer may be used for this purpose, and Freeman's 
conclusions are as follows : First, milk for infant feeding should be pasteur- 
ized so as not to interfere with its biological properties or chemical com- 
position, but at a sufficient temperature to destroy the bulk of the bacteria 
present, including the tubercle bacilli. Second, a temperature of 140° F. 
(60° C.) continued for forty minutes would seem to fulfil these indica- 
tions. Freeman also says the question "concerning the effect of heat on 
ferments has been carefully worked out by Hippius. The salol-splitting fer- 
ment found only in mother's milk was weakened by a temperature of 131° 
F. (55° C.) and destroyed by 149° F. (65° C), while the anxiolytic fer- 





Fig. 20. — Freeman's Pasteurizer. 
A, Bottles in position for heating; B, method of cooling. 

ment found only in mother's milk was weakened by a temperature of 158° 
F. (70° C.) and destroyed by 167° F. (75° C.)." 

It seems evident therefore that the pasteurization of milk when care- 
fully done may serve the purpose of checking the fermentative processes 
without materially changing its chemical composition or biological proper- 
ties, and clinical experience strengthens this opinion since milk pasteurized 
at low temperatures may be fed for a long time with practically the same 
results as are obtained from fresh, clean raw milk. Pasteurized milk, how- 
ever, requires time, care and intelligence in its preparation, and also re- 
quires a subsequent refrigerator temperature to prevent bacterial contamina- 
tion. It is therefore not commonly available for use among the poor of our 
large cities. It has, however, a large field of usefulness among those city 
dwellers who have the time and intelligence to prepare it and the facilities 
to care for it after its preparation, since in our large cities even the best 
available milk during the hot summer months is rendered safer by pasteuri- 
zation. 

Peptonized Milk. — Milk may be partially or wholly peptonized for the 
purpose of feeding premature infants, malnourished infants and those suf- 
fering from acute or chronic gastrointestinal disorders. In the handling 
of this class of infants there is unquestionably a field for the use of pep- 



122 ARTIFICIAL FEEDING OF INFANTS 

tonized milk. Many infants with feeble digestive capacity are capable of 
digesting and assimilating modified, peptonized milk in sufficient quanti- 
ties to prevent rickets and other malnutritions which would follow if they 
were fed upon very weak milk mixtures. There are many children also who, 
after a long and severe gastrointestinal illness, do not recover for many 
months their capacity to digest unchanged milk. These children com- 
monly thrive on peptonized milk, and it is sometimes even necessary to 
keep them on it until they reach the age when other foods may be added 
to their diet. In recommending peptonized milk it is also important to 
call attention to the fact that the child's digestive capacity may remain 
undeveloped if the peptonized milk be too long continued. As Chapin has 
forcibly noted the stomach of the infant must be gradually educated to 
digest milk, and this physiological process influences the anatomical and 
physiological development of the digestive organs. The physician must 
therefore not abuse the use of peptonized milk, nor on the other hand 
should he condemn the infant to rickets or other forms of malnutrition 
because of his fear that peptonized milk may weaken the infant's digestive 
capacity. Partially peptonized milk is prepared by using peptonizing 
tubes, one tube to a pint of milk, with a little bicarbonate of soda to pre- 
vent coagulation. The milk is peptonized at a temperature of 110° F. for 
ten or fifteen minutes and then immediately placed on ice to stop further 
peptonization. If after standing for several hours the peptonized milk is 
so bitter that the infant will not take it, sufficient cane sugar may be added 
for sweetening purposes. It is better not to boil the milk after peptoniza- 
tion, as this destroys the peptonizing ferments that have been added to the 
milk and produces other undesirable changes in the milk which have been 
previously referred to. It may be necessary in some instances to com- 
pletely peptonize the milk. This is done in the same manner as above 
described except that the milk is kept warm and the peptonizing process 
continued for one and a half to two hours. This process makes the milk 
bitter and it is always necessary to overcome this bitter taste with cane 
sugar or saccharin. 

Buttermilk. — Buttermilk as a food for infants deserves careful con- 
sideration. It has long been successfully used in Holland. In recent years 
the experience of physicians the world over has demonstrated that it may 
be a valuable substitute for cow's milk in infants suffering from various 
forms of gastrointestinal disturbance. Buttermilk used in infant feeding 
is commonly made from cream or milk that has soured naturally. The 
souring process in the milk, however, may be started or hastened by modu- 
lation with sour milk or with lactic acid bacilli from a culture. The latter 
process, however, is not commonly practicable for the general practitioner. 
The composition of buttermilk varies. In the average, however, it contains 
about 1 per cent, of fat, 4 per cent, of sugar, and 3 per cent, of proteins. 
It has a food value of about 400 calories to the quart. It is commonly pre- 
pared for infant feeding as follows : To one quart of buttermilk are added 
two level tablespoonfuls of wheat flour and one level tablespoonful of cane 



COW'S MILK 123 

sugar. This mixture is, with constant vigorous stirring, slowly brought to 
the boiling point and kept there for twenty minutes, and then allowed to 
cool. The constant stirring prevents the coagulation of casein. Butter- 
milk prepared in this way has the same percentage of fat and protein as 
above given, but the carbohydrates have been increased to 10 per cent, and 
the food value of the mixture has been increased to 600 calories per quart. 
This buttermilk mixture, when considered from the standpoint of infant 
foods, contains a low percentage of fat and a comparatively high percentage 
of proteins and a very high percentage of carbohydrates. The casein is 
very finely divided, separated from its calcium base and appears in the form 
of the lactate of casein which cannot be acted upon by rennet, but which is 
readily digested by the intestinal ferments. The acidity varies in the 
neighborhood of 0.5 per cent. The chief value therefore which buttermilk 
has, when prepared as above described, lies in the comparatively large quan- 
tity of easily digested casein which it contains, the small amount of fat, and 
the large quantity of easily digested carbohydrate which substitutes for the 
fat in serving the nutritional demands of the body. Buttermilk, notwith- 
standing the fact that it may be used in the feeding of well infants for some 
months at a time without producing apparent nutritional disturbances, is 
an ill-balanced food mixture, not capable of satisfying the full nutritional 
demands of the rapidly growing infant. It is to be used therefore as a 
food for normal infants only when properly modified cow's milk cannot be 
obtained. Its real field of usefulness, however, is as a substitute for cow's 
milk in infants who are suffering from gastrointestinal disturbances and 
who are not capable of digesting cow's milk. It has been used with success 
in chronic and subacute gastroenteritis, infantile atrophy and acute gastro- 
intestinal indigestion. This buttermilk mixture may be modified by the 
addition of boiled water to suit the age and digestive capacity of the infant. 
Finkelstein's Albumin Milk. — Take one quart of boiled milk; after it 
is cool remove from the top the thick scum, then add to it a liquid rennet 
(1 ounce of commercial essence of pepsin) and allow it to coagulate for 
one hour at a temperature of 42° C. in a warm bath. Then thoroughly 
stir so as to break the coagulated casein into fine particles, and pour it into 
a bag of cheesecloth to drip for one hour. The casein is then removed from 
the bag and stirred into a pint of water and worked with a wooden spoon 
through a fine sieve. A pint of boiled buttermilk is then added and the 
whole mixture is again worked through a fine sieve until the casein is so 
finely broken up that it looks like ordinary milk. I have had a large and 
favorable experience during the last two years with Finkelstein's milk pre- 
pared as above directed. This mixture is said to contain 3 per cent, of 
protein, 2.5 per cent, of fat, 1.5 per cent, of sugar, and 0.5 per cent, of ash. 
It is therefore almost a sugar-free mixture very rich in casein and con- 
taining a fair percentage of fat. It is recommended in sugar intoxications. 
I have found it of special value in infants under two years of age suffering 
from chronic gastrointestinal indigestion. Under this food very commonly 
fever, diarrhea and toxic symptoms subside and the infant gains in strength, 



124 ARTIFICIAL FEEDING OF INFANTS 

stops losing weight and in some instances there is a slight gain. After 
this mixture has been used for two or three weeks I have found it advisable 
to begin the use of codliver oil ; with this addition the infant commences to 
gain in weight, and thereafter thick cereal gruels in small quantities may 
be added. Later, as the infant becomes convalescent, ordinary modified 
milk formulas may be gradually substituted and the Finkelstein milk dis- 
continued. During the use of this formula constipation must be combated 
by the use of milk of magnesia or some other laxative. 

Malt Soups.— Malt soups, introduced by Keller (Breslau), will some- 
times agree with infants that have failed to thrive on the ordinary milk 
formulas. These soups are rich in carbohydrates and weak in fat and pro- 
tein. The excess of carbohydrate is, however, well borne, and Keller be- 
lieves that in malt soups less protein is lost by intestinal fermentation and 
therefore more absorbed than in other milk foods. However this may be, 
the fact remains that the "malt soup" is of value in the feeding of some 
difficult cases. It is made as follows: One ounce (by weight) of wheat 
flour is rubbed up with enough cold milk to prevent lump forming and then 
mixed with 10 ounces of milk. This is heated slowly with constant stirring 
for twenty minutes and allowed to cool. In a separate vessel dissolve 3 
ounces of one of the thick malt extracts (such as Maltine or Maltzyme) in 
20 ounces of lukewarm water which contains 15 grains of potassium car- 
bonate. This is then added to the milk and flour mixture and kept warm 
for two or three minutes and then rapidly heated with constant stirring for 
five minutes. Cool and the mixture is ready for use. It may be diluted, if 
necessary, for young infants. 

Skimmed Milk. — Skimmed milk has only about 1 or 1% per cent, of 
fat, but it has practically the same amount of sugar and protein as whole 
milk. It is of great value as a substitute for whole milk in infants suffer- 
ing from gastrointestinal disturbances and in all other cases where there 
is an inability to digest the fat of cow's milk. Experience has demonstrated 
that skimmed milk has a wide field of usefulness as a temporary food in 
these cases. It should be modified by the addition of a carbohydrate mix- 
ture to suit the age of the infant, and if it is given for any length of time 
the carbohydrates should be added in excess to make up in caloric value for 
the loss in fat. As the infant regains its capacity for fat digestion the 
quantity of carbohydrates should be gradually diminished and the fat grad- 
ually increased so as to prevent nutritional disturbances which might result 
from the long-continued use of a food markedly deficient in fat. 

CARBOHYDRATES 

Carbohydrates, including the sugars and starches, play a most important 
role in modified milk mixtures. 

Milk Sugar. — Milk sugar has for many years been in high favor be- 
cause it is a natural ingredient of milk and because it can, as a rule, be fed 
in sufficient quantities to produce good nutritional results without pro- 



CARBOHYDRATES 125 

during gastrointestinal disturbances. Milk sugar, however, is more sus- 
ceptible to fermentation and is not so readily assimilated as maltose and 
dextrin, and is therefore not an infrequent cause of intestinal fermentation 
and of the symptom group elsewhere spoken of under the term "sugar in- 
toxication." On the whole, however, milk sugar is a safe and satisfactory 
form in which to administer carbohydrates. It is commonly used in 5 to 
7 per cent, solutions dissolved in boiling water. But when fermentative 
changes occur in the intestinal canal the milk sugar should be suspected 
as the primary cause and the quantity of sugar diminished or a maltose- 
dextrin mixture substituted for the milk sugar. 

Cane Sugar. — Cane sugar may also be used in the same manner as milk 
sugar, but because of its sweetness it cannot, as a rule, be used in large 
enough quantities to supply the carbohydrate demand of a modified milk 
mixture, and when given in excess commonly causes a fermentative diarrhea. 
Cane sugar, however, is very commonly used in small quantities to sweeten 
cereal decoctions. Cane sugar, like milk sugar, may also produce intestinal 
fermentation, and when this occurs it should be discontinued and a mal- 
tose-dextrin mixture substituted. 

Maltose. — Maltose has for many years been considered one of the most 
valuable of infant foods in modifying milk formulas; but the German 
school in the last few years has called special attention to the value of this 
sugar as a substitute for milk and cane sugar in conditions of intestinal 
fermentation. It is more easily assimilated and more rapidly absorbed 
than lactose or saccharose and it may be taken therefore by the infant in 
larger quantities without producing sugar fermentation. The ferments 
which convert milk sugar and cane sugar occur exclusively in the intestinal 
canal, so that if this digestive process is not completed in the intestinal 
tract the partially converted sugars may be absorbed and produce a sugar 
intoxication. While, on the other hand, the ferment which converts maltose 
occurs not only in the intestinal canal, but in other parts of the body, so 
that, if partially converted maltose is absorbed, sugar intoxication is, as a 
rule, prevented by the further action of this ferment after this form of 
sugar has been absorbed, and this fact may partially explain the fact that 
the feeding of maltose rarely produces sugar in the urine. 

Maltose is especially indicated in the feeding of very young and deli- 
cate infants, and in all cases where either milk or cane sugar has produced 
intestinal fermentation and sugar intoxication. In the feeding of maltose 
it has been found advisable to combine it with about equal parts of dextrin. 
In Germany, and later in this country, "Soxhlet's Nahrzucker" (which con- 
tains maltose 52.44 per cent., dextrin 41.26 per cent., and sodium chlorid 
2 per cent.) has been largely used. Mead's Dextri-Maltose (malt sugar), 
which contains about equal parts of dextrin and maltose, is a similar 
preparation which may be used instead of milk sugar or cane sugar for 
modifying milk mixtures. These dextri-maltose preparations have about 
the same caloric value as milk sugar, but, according to the experiments of 
Reuss, Grosz and others, their relative absorption per kilogram of body 



126 



ARTIFICIAL FEEDING OF INFANTS 



weight as compared with milk sugar and cane sugar is as 7.7 to 3.1 grams. 
Mellin's food is a proprietary maltose dextrin mixture containing three or 
four times as much maltose as dextrin. 

Cereal Decoctions. — Cereal decoctions such as barley, oatmeal and rice- 
water may be prepared by adding a slightly rounded tablespoonful (y 2 
ounce) of barley flour, oatmeal or cracked rice to a pint of water and boil- 
ing for thirty or forty minutes, and then adding hot water to the mixtures 
to supply the loss from evaporation, so that the cereal decoctions will repre- 
sent a pint of fluid for every tablespoonful of the cereal used. This makes 
approximately a 3 per cent, starch mixture. These cereal decoctions, es- 
pecially barley water, have been strongly recommended by Jacobi for many 
decades and are now very generally used by the medical profession. They 
serve the double purpose of furnishing an easily digested carbohydrate food 
and of causing the casein to be precipitated in fine curds. 

Dextrinized Gruels. — Dextrinized gruels are made by adding to one pint 
of a lukewarm cereal decoction, such as barley water, one tablespoonful of 
one of the thick malt extracts such as maltine or maltzyme, and, after five 
or ten minutes of stirring, the mixture is brought to a boil. Dextrinized 
gruels contain a variable amount of starch, dextrin and maltose. If the 
dextrinizing process lasts longer than thirty minutes all the starch is con- 
verted into dextrin and maltose. Experience has taught that a cereal 
decoction in which about one-half the starch is converted into dextrin 
and one-half into maltose, offers one of the best carbohydrate mixtures for 
infant feeding, and this result can be approximately obtained by dextrin- 
izing the cereal decoction for ten minutes. Dextrinized gruels prepared 
in this way are especially adapted to furnish young and delicate infants 
with a carbohydrate food which is more easily digested and assimilated 
than the unmalted cereal decoctions. The old-fashioned "flour ball" is 
prepared by tying in a cloth a ball of wheat flour four or five inches in 
diameter, suspending it in boiling water five or six hours and then un- 
covering and drying the flour. The starch by this process is partly con- 
verted into dextrin. One tablespoonful of this partially dextrinized flour 
when mixed and boiled in one pint of water makes a very good carbohydrate 
mixture for modifying cow's milk. 

Condensed Milk. — Condensed milk is prepared by evaporating cow's 
milk about one-fourth in volume. It is preserved by the addition of con- 
siderable quantities of cane sugar — five or six ounces to the pint. 

The composition of condensed milk is shown in the following table 
from Holt : 





Condensed 
Milk 


With 6 Parts of 
Water Added 


With 12 Parts of 
Water Added 


With 18 Parts of 
Water Added 


Fat 


Per Cent. 
6.94 
8.43 

50.69 

1.39 
31.30 


Per Cent. 
0.99 
1.20 

7.23 

0.17 
90.49 


Per Cent. 
0.53 
0.65 

3.90 

0.10 
94.82 


Per Cent. 
0.36 




0.44 


o 110>Qr J Cane 40.44 | 

Sugar j MUk 1Q 25 \ 

Salts 


2.67 
07 


Water 


96.46 







CARBOHYDRATES 127 

An examination of the percentages given 'in this table shows that con- 
densed milk is not a properly balanced food for infant feeding. It is 
notably deficient in fats and proteins and contains too much sugar, so that 
infants fed exclusively upon this food for any length of time must suffer 
more or less seriously from nutritional disturbances. Condensed milk 
babies have feeble powers of resistance. Their teeth and bony skeleton 
are slowly and imperfectly developed and they are commonly fat, flabby, 
rachitic and anemic. But notwithstanding the fact that the long-continued 
use of condensed milk almost invariably produces more or less serious mal- 
nutrition it is a very valuable temporary food for infants under certain 
conditions. Its advantages are that it is easily digested, sterile, cheap, 
easily prepared, and easily cared for. It is therefore of great value among 
the poor of our large cities who cannot afford to buy clean cow's milk and 
who have not the facilities for keeping cow's milk clean and wholesome, 
even if it were furnished to them. Thousands of infants in our large 
cities are carried through the summer months on condensed milk who 
would have died from gastroenteric troubles if their mothers had been com- 
pelled to feed them upon such cow's milk as they could procure, and these 
rachitic, malnourished babies, who have passed through the crisis of their 
existence on condensed milk, as the cooler weather comes may gradually 
overcome these malnutritions by the addition to their diet of more whole- 
some food. In the care of condensed milk babies the physician, realizing 
the importance from a nutritional standpoint of substituting cow's milk for 
this food, too often makes the change more rapidly than the child's digestive 
capacity will permit and thereby adds a gastrointestinal disturbance to the 
malnutrition. When it is practicable these infants should have cow's milk 
added very gradually to the condensed milk mixture so that it may in time 
gradually displace the condensed milk mixture without disturbing the in- 
fant's digestive capacity. 

PROPRIETARY FOODS 

Nestle's Food. — Nestle's food is one of the most easily digested of the 
proprietary milk foods. It is a valuable temporary substitute for cow's milk 
in infants suffering from acute gastrointestinal disturbances. Nestle's food 
is also one of the worst of the proprietary foods for continuous administra- 
tion. Its long-continued use as the sole article of diet very commonly pro- 
duces severe forms of rickets and scurvy. Chittenden's analysis of Nestle's 
food, prepared according to directions for infants of six months, shows that 
this mixture has only 0.81 per cent, of albuminoids and 0.36 per cent, of 
fat. This marked deficiency in fat and protein renders it quite unfit to 
serve the nutritional demands of the infant for any great length of time. 
When Nestle's food is used as a substitute for milk mixtures in the gastro- 
intestinal disturbances of infancy it should, as soon as the condition of the 
gastrointestinal canal will permit, have added to it small quantities of milk, 
and as the child convalesces the milk is slowly increased and the Nestle's 
10 



128 



AETIFICIAL FEEDING OF INFANTS 



food mixture diminished, until a modified milk formula replaces the Nestle's 
food. When for any reason it is necessary to continue Nestle's food for 
any length of time and cow's milk cannot be added to the mixture, the 
infant should be given as supplemental foods orange juice and codliver oil. 
By these additions it may be possible to prevent the scurvy and rickets 
which otherwise might follow. 

Malted Milk. — Malted milk is a proprietary milk food which, like 
Nestle's food and condensed milk, is very poor in fat and in the total quan- 
tity of solid matter it contains. It is therefore not to be recommended as 
an exclusive food for infants. It may, however, be used as a temporary 
substitute for milk as in traveling or where for any other reason cow's 
milk is not available. It is, like condensed milk, very extensively used 
among the poor of our large cities, because it is easily digested, easily pre- 
pared, and serves the purpose of tiding the infant over the hot summer 
months. 



CHITTENDEN S TABLE 



Composition of some infants foods as prepared for the nursing-bottle in comparison with mother's milk. 
Prepared according to directions for infants of stx months. 



Peptogenic 
Powder 



Specific gravity 

Water 

Total solid matter... 

Inorganic salts 

Total albuminoids. . . 
Soluble albuminoids . 
Insoluble albuminoid 

Fat 

Milk sugar 

Cane sugar 

Maltose 

Dextrin 

Soluble starch 

Starch 

Reaction 



Mother's 


Malted 


Nestle's 


Imperial 


Mellin's 


Milk 


Milk 


Milk Food 


Granum 


Food 


1031 


1025 


1024 


1025 


1031 


86.73 


92.47 


92.76 


91.53 


88.00 


13.26 


7.43 


7.24 


8.47 


12.00 


0.20 


0.29 


0.13 


0.34 


0.47 


2.00 


1.15 


0.81 


2.15 


2.62 


2.00 


1.15 


0.36 


1.67 


2.62 





trace 


0.45 


0.48 





4.13 


0.68 


0.36 


1.54 


2.89 


6.93 


1.18 


0.84 


2.71 


3.25 








2.57 











3.28 


trace 


trace 


2.20 






0.92 



j- 0.44 


0.58 -j 


0.53 









1.99 


1.22 





alkaline 


alkaline 


alkaline 


alkaline 


alkaline 



1032 
86.03 
13.97 

0.26 

2.09 

2.09 



4.38 

7.26 










alkaline 



ALBUMIN WATER 



Albumin water is prepared by adding the white of an egg to 8 ounces 
of boiled water which may be slightly flavored with salt. This food is very 
largely used in acute gastrointestinal disturbances as a temporary substitute 
for cow's milk where the latter is contraindicated. The fact that it has 
been used in this way for many years and still remains a favorite with the 
medical profession is evidence that it is a valuable substitute food in the 
treatment of these conditions. In my experience, however, albumin water 
has not acted as kindly in these conditions as barley water and other sub- 
stitutes that are used for the same purpose. It is valuable as a food in 
the regular diet of infants over eight months of age. 



VALUE OF PERCENTAGE FEEDING 129 

MEAT PREPARATIONS 

Beef Juice. — Fresh beef juice may be prepared by slightly singeing a 
beefsteak on both sides and then cutting it into small pieces about half an 
inch square and expressing the juice with a meat press. The singeing of 
the beefsteak answers the double purpose of partially sterilizing the steak 
and of giving to the expressed juice the flavor of cooked meat. When pre- 
pared in this way beef juice according to Holt has the following com- 
position : 

Proteins 2.90 per cent. 

Fat 0.60 per cent. 

Extractives 3.40 per cent. 

Salts 0.20 per cent. 

Water 92.90 per cent. 

It will thus be seen that beef juice contains approximately 3 per cent, 
of albumin. It is a valuable food for infants during the second year of life 
and may be given, if necessary, as a supplemental food during the last three 
months of the first year. It is also a valuable substitute food in all gastro- 
intestinal disorders where milk is contraindicated. It is not only easily 
cared for by the digestive organs of the infant, but is a stimulant and food 
of great value in many cases where other foods are but poorly tolerated. 

Broths.' — Broths made from mutton, beef, and chicken to which a cereal 
has been added, in the proportion of one tablespoonful to the pint of broth, 
are valuable foods which enter into the dietary of the child during the 
"second year of life. The plain animal broths made from beef and mutton, 
and from which the fat has been carefully skimmed, are useful substitute 
foods in the gastrointestinal disturbances of infancy where milk is contra- 
indicated. These broths contain only about 1 per cent, of protein and 
therefore are of little value as foods, but they are stimulating and satisfy- 
ing and may be used temporarily during the starving process in all condi- 
tions of infancy where it is necessary to temporarily withhold other foods. 



CHAPTEE XIV 
AKTIFICIAL FEEDING 

VALUE OF PERCENTAGE FEEDING 

The percentage composition of human milk is of great interest in that 
it gives the actual and relative amounts of fat, proteins, sugar and salts 
which the ideal infant food contains. There is no doubt but that the 
various ingredients *of human milk are combined in actual and relative 
amounts to suit the digestive capacity and the nutritional demands of the 
human infant. Neither is there any doubt but that the formula of human 
milk would be our best guide in making an artificial food for infants if the 



130 ARTIFICIAL FEEDING 

various ingredients of cow's milk resembled in every particular those of 
human milk. Both of these statements are self-evident facts, and upon 
them the American school of pediatricians has made percentage feeding 
the underlying principle in the artificial feeding of infants. By percentage 
feeding is meant that the percentages of the chief ingredients of an infant 
food shall be combined in proper proportions to meet the nutritional de- 
mands and suit the digestive capacity of the individual infant. In making 
an artificial food if one had only to consider the nutritional demands of an 
infant it would be an easy matter to write out a food formula conforming 
in the percentages of its principal ingredients to human milk, but as one 
has also to consider the food idiosyncrasies as well as the digestive and 
assimilative capacity of the individual infant for a food whose principal 
ingredients are derived from cow's milk and which are, as pointed out in 
another chapter, chemically, biologically, and physiologically different from 
the ingredients of human milk, it follows that the percentage formula of an 
infant food to meet these conditions must differ materially from woman's 
milk. An artificial food therefore, under the percentage or any other method 
of feeding, must be constructed primarily to conform to the digestive ca- 
pacity of the infant, but in conforming to this standard the various in- 
gredients of the food mixture should not differ in their relative proportions 
so widely from the composition of mother's milk as to produce a partial 
starvation in either protein, fat, carbohydrates or salts. If both the diges- 
tive capacity and the nutritional demands of the infant are considered in 
the making of an artificial food, more or less accurate relative percentage 
values must be maintained and experience has demonstrated that this is a 
practical and scientific method of feeding. The only danger in this method 
is that the physician may be so impressed with its accuracy that he may 
give more attention to his method than he does to the digestive capacity 
and nutritional demands of the individual infant. 



CALORIC STANDARD 

The caloric value of woman's milk is of great interest in that it fur- 
nishes us with an accurate standard of the food value of the ideal infant 
food. 

A calorie is the amount of heat required to raise the temperature of one 
kilogram of water 1° C. ; this is the unit of value by which the heat- or 
energy-producing values of various foods are measured. The ingredients of 
milk have the following caloric values : 

1 gram of protein will produce 4.1 calories 

1 gram of fat will produce 9.1 calories 

1 gram of sugar will produce 4.1 calories 

Spiegelberg says: "From calculations made by different authors it can 
be said that a strong breast-fed baby in the first two months consumes daily 
about one-fifth of its body weight of milk. In the second quarter of the 



CALORIC STANDARD 131 

year this diminishes to one-sixth or one-seventh. In the latter months of 
the year to one-eighth or one-ninth of the body weight. A two-months-old 
child therefore weighing 4,000 grams would take one-fifth of 4,000 — that 
is to say, 800 grams each day. A seven-months-old child weighing 7,000 
grams would take 1,000 grams." 

These values accord with those given by Heubner, that infants consume 
daily during the first three months an amount of milk equal to 45 calories 
per pound of body weight ; during the next quarter about 43 calories ; dur- 
ing the third quarter about 38 calories, and during the last quarter of the 
first year of life about 34 calories. In general terms therefore one may say 
that an infant's food should have a caloric value of 40 for every pound of 
body weight. A twenty-pound infant would require 800 calories in twenty- 
four hours. In young infants one may have to slightly increase and in older 
infants slightly diminish these values. 

To determine the number of calories in a food mixture multiply the 
number of ounces of each ingredient used in twenty-four hours by the fuel 
value of an ounce of this food, add the products and the sum will represent 
the caloric value of the food. The following table shows the energy quo- 
tients of different materials used in infant feeding : 

1 qt. of whole milk contains 690 calories 

1 qt. of % whole milk contains 460 calories 

1 qt. of y<z whole milk contains 350 calories 

1 qt. of % whole milk contains 230 calories 

1 qt. of buttermilk contains 410 calories 

1 qt. of ordinary skimmed milk contains 410 calories 

1 qt. of fat-free skimmed milk contains 320 calories 

1 oz. of fat-free skimmed milk contains 10 calories 

1 oz. of ordinary skimmed milk contains 13 calories 

1 oz. of whole milk contains 21 calories 

1 oz. of buttermilk contains 13 calories 

1 oz. of 7 per cent, top milk contains 31 calories 

1 oz. of 10 per cent, top milk contains 39 calories 

1 oz. of 16 per cent, cream contains 54 calories 

1 oz. of carbohydrate contains 120 calories 

From this table it will be easy to determine the caloric value of any 
food mixture. Take for example the following : 

Top milk 7 per cent, fat 16 oz. = 31x16 = 496 calories 

Sugar of milk 2 oz. = 120 X 2 = 240 calories 

Water 13 oz. 



31 oz. = 736 calories 

The value of the above food formula is therefore 736 calories, and, 
since 40 calories are required for each pound of body weight, if we divide 
736 by 40 we find that the above food mixture has the requisite number of 
calories to feed an 18-pound baby twenty-four hours. 

The calorimetric standard of the German school is the only accurate 
method we possess for determining the amount of food an infant should 
take in twenty-four hours, and the importance of utilizing this standard 



132 ARTIFICIAL FEEDING 

to prevent the over- or underfeeding of infants should be insisted upon, as 
by this standard alone can we be sure, in varying the different ingredients of 
an artificial food mixture to suit the digestive capacity of the infant, that 
we are giving it a food the energy equivalent of which will accurately 
satisfy all the demands of the body. The calorimetric standard, however, 
must not for a moment be considered as a method of feeding or as the 
sole or all-important principle upon which a baby food is to be constructed. 
It is simply a standard which prevents the over- or underfeeding of infants 
by whatever method we adopt. An infant may be fed the proper number of 
calories of an ill-balanced food, such as condensed milk and the various 
patent milk foods, and yet suffer serious nutritional disturbances because 
of the relatively low percentages of fats and proteins in these foods. This 
illustration emphasizes the fact that the proteins, fat and carbohydrates, 
apart from their caloric values, have definite and distinct purposes to serve 
in supplying the nutritional demands of the infant. It follows therefore 
that the percentage method of feeding, which gives to the infant the rela- 
tive quantities of fat, carbohydrates, proteins and salts it needs, must ever 
remain the basis of scientific infant feeding, and that in using this method 
one should, to secure fairly accurate quantities, conform, within certain 
limits, to the calorimetric standard, and should, to prevent or correct gas- 
trointestinal disturbances, change the percentages of the various food in- 
gredients to conform to the digestive capacity and food idiosyncrasies of 
the individual infant. 

PRINCIPLES OF ARTIFICIAL FEEDING 

Success in infant feeding depends not upon the particular method used, 
but upon the intelligence, the experience and the knowledge of the under- 
lying principles of infant feeding which the physician possesses. Methods 
of infant feeding are to experienced physicians what tools are to artisans. 
As one artisan may be more skilled in the use of a certain tool than an- 
other, so one physician may be more skilled in the use of a certain method 
of feeding than another. The principles which underlie the art of infant 
feeding are, therefore, so much more important to success than are indi- 
vidual methods that one is justified in trying to so formulate these principles 
that they may form the nucleus around which the young physician may 
build the clinical experience which will enable him more intelligently to 
use whatever method of infant feeding he may choose. 

The principles underlying the artificial feeding of infants do not and 
possibly never will constitute an exact science, since the capacities and 
idiosyncrasies of infants in the digestion and assimilation of protein, fat, 
carbohydrates and salts cannot be foretold. There must therefore always 
remain certain difficulties to be overcome by experimentation. These experi- 
ments, however, should be carried along certain lines derived from clinical 
experience. The following principles derived from this source will be of 
value in the artificial feeding of infants. 



PRINCIPLES OF ARTIFICIAL FEEDING 133 

I. Clean milk is absolutely necessary to success in infant feeding. Un- 
clean milk cannot by any process be made into a safe and wholesome infant 
food; if pasteurization is necessary clean milk must be used to start with. 
This principle of infant feeding is absolutely essential and is much more 
important to success than methods of modification. Cream is always much 
more contaminated with bacteria than milk of the same age, and com- 
mercial cream, which is from twelve to twenty-four hours older than milk, 
contains a bacterial content so large that it is unsafe for infant feeding. 
If it be necessary to increase the amount of fat in an infant's food this 
may be done by taking a certain percentage from the top of clean milk. 
In this way one obtains a clean, wholesome cream. The formulas for the 
making of cream mixtures which are so widely spread among the laity are 
the cause of no small part of the digestive disturbances which occur in 
infants. The milk used in infant feeding should come preferably from 
common cows (Holstein and Ayrshire) rather than from highly bred ones 
of the Alderney or Jersey variety. The milk from highly bred cows con- 
tains too high a percentage of fat and this fat is not as digestible as that 
found in the milk of the common cow. 

II. The infant should be placed upon a food formula which contains 
about the requisite number of calories. If, however, it fails to thrive and 
the gastrointestinal conditions remain normal the number of calories (the 
strength or quantity of the food) should be increased. An infant should 
never be allowed to starve because it fails to thrive on the number of calo- 
ries which a mathematical calculation awards it. On the other hand, if an 
infant has become ill on a food formula one of the first inquiries to make 
is as to whether it is being overfed in calories. 

III. Overfeeding, not only in the number of calories but also in the 
number of ounces given, is the cause of many failures in infant feeding. 
It is most important therefore that the number of ounces taken by the indi- 
vidual infant should be adjusted to suit the capacity of its stomach. To 
overfeed in ounces given will cause gastric and intestinal disturbance or 
will result in dilatation of the stomach with chronic gastric indigestion 
which months of careful feeding are required to overcome. To give an in- 
fant all it will take is a very common practice and one fraught with the 
gravest dangers. The capacity of the stomach of the average newly born in- 
fant is about one ounce and in premature infants it is less. The stomach 
grows in size rapidly for the first four months, at which time its capacity 
is about 5 or 6 ounces. After the fifth month the stomach develops less 
rapidly, so that at ten months it should hold about 9 or 10 ounces. At 
one year of age the stomach should hold from 10 to 12 ounces. Under one 
year of age the total quantity of liquid given in twenty-four hours should 
not exceed 40 or 45 ounces. In under- or oversized infants the number of 
ounces given may be slightly increased or diminished to suit the weight of 
the child. Overfeeding, in the number of calories given, is also one of the 
most common causes of digestive disturbance in infancy. But under these 
conditions the overfeeding does not always refer to an excessive fuel value 



134 ARTIFICIAL FEEDING 

of all of the ingredients of the food, but may be due to a great preponder- 
ance of the carbohydrates, fats or whey salts. The important fact to bear 
in mind is that infants may be made ill with a perfectly wholesome food 
if given in excessive quantities and the overfeeding may comprehend an 
excessive quantity of all or of any one of the ingredients of its food. 

IV. Artificially fed infants should be given their food at regular inter- 
vals. This is absolutely necessary to obtain the best results. The infant 
must be fed not only regularly but the interval between the feedings must 
be carefully adjusted to suit its age, weight and digestive capacity. From 
the end of the first week to the end of the fourth week a two-hour interval 
should be maintained ; during the second and third months a two-and-a-half- 
hour interval ; from the third to the sixth month a three-hour interval, and 
thereafter a four-hour interval. These periods should be observed with 
the strictest regularity, between the hours of 6 A. M. and 10 P. M., until 
the child is five months of age, and between the hours of 10 P. M. and 
6 A. M. a much longer interval should be observed. After the fifth month 
the night feeding should be discontinued. When eight months of age the 
infant should have but four feedings in twenty-four hours, beginning at 
6 or 7 A. M. and finishing at 6 or 7 P. M. 

V. Eest for the nervous system is a most important aid to infantile 
digestion. Infants should be taught to lie quietly without coddling and 
should live in quiet surroundings, so that they may get the full amount of 
sleep due them. The immature nervous system of the infant, when excited 
by outside causes, exerts a most profound influence over the digestive 
organs. 

VI. Fresh air is perhaps the most important outside aid in improving 
the digestive capacity of the infant. As soon as possible, after the first 
month in winter and almost from birth in summer, it should be taught to 
live and sleep during the greater portion of the day in the open air. North- 
rup has laid great stress upon the fact that it is quite as important for suc- 
cess in infant feeding "to modify the baby" by rest and fresh air as it is to 
modify the food. 

VII. The infant's food should contain fat, protein and carbohydrates 
in fairly accurate percentages; that is to say, these ingredients should be 
combined in such relative quantities as will best meet the nutritional de- 
mands of the infant. Should it be necessary in the treatment of digestive 
disturbances to change the food formula by markedly cutting down either 
the fat or the protein, the physician should be most careful to see that the 
permanent formula adopted during convalescence should return in fat and 
protein as nearly as possible to the original formula. The necessity for 
this lies in the fact that no other food ingredient can take the place of 
protein, and that while the carbohydrates may for a time partially substi- 
tute for fat, the continued use of very low fat percentages will in time pro- 
duce serious nutritional disturbances. The partial starvation of infants 
in protein, fat, and salts results in rickets, scurvy, anemia and other mal- 
nutritions. These ingredients should therefore, within the limitations of the 



HOME MODIFICATION OF MILK 135 

child's digestive capacity, be gradually restored to the quantities which the 
age and weight of the child demand. 

VIII. The fat of cow's milk is not as readily digested as that of hu- 
man milk. It is therefore wise to place the percentages of fat in modified 
milk mixtures for young infants much lower than it is in human milk. 
Excess of fat is one of the most common early causes of indigestion. To 
correct this condition the first trial change to be made in the food formula 
is a reduction of fat (cream) and a corresponding increase, in calories, of 
the carbohydrates. The indications for this change are strengthened if the 
infant has the following symptoms: Habitual regurgitation, constipation 
with gray, dry stools, or loose movements with small, soft curds and an 
irritating urine with an ammoniacal odor. 

IX. The casein of cow's milk may be a cause of indigestion. If, there- 
fore, the reduction of fat fails to correct the trouble an effort should 
be made to prevent the coagulation of casein in the stomach, by adding to 
the food sodium citrate, alkalies or cereal decoctions, or perhaps by boiling 
the milk. If these measures fail the casein may be diminished and the whey 
proteins added to make up the deficiency. When the cause of the trouble is 
thus righted the fat and the protein may be slowly increased to the original 
formula. Casein indigestion is indicated by large, tough curds, putrid, 
loose, brownish, alkaline stools, fever and other constitutional symptoms. 

X. The carbohydrates, including the sugars, are the most easily di- 
gested of the food ingredients of a modified milk mixture, and for this 
reason they are not uncommonly increased at the expense of fat and pro- 
tein. Under such conditions a carbohydrate indigestion and sugar intoxica- 
tion may result. This may be indicated by a watery, acid, nonputrid 
diarrhea which produces irritation of the buttocks and which is frequently 
associated with fever, severe constitutional symptoms, much gas forma- 
tion and intestinal catarrh. When this occurs the sugars must be tem- 
porarily eliminated from the diet until these symptoms subside and then 
a different carbohydrate (sugar) should be added, preferably one that con- 
tains a large percentage of maltose and dextrin, since they are less liable 
to produce fermentation than any of the other sugars or starches. 

HOME MODIFICATION OF MILK 

The home modification of milk is almost universally used for infant 
feeding. The term "home modification" carries with it no definite condi- 
tions for the modification of milk. It is simply a general term used to 
cover all methods by which milk is modified at home with the idea of 
making it more suitable to the digestive capacity and nutritional demands 
of the infant. Nearly every physician of experience has worked out for 
himself a plan for modifying milk which his clinical experience has taught 
him will serve his purposes better than any other that he has been able 
to find, and nearly every author offers his own plan for the home modifica- 
tion of milk by which a certain degree of accuracy in percentage feeding 



136 



ARTIFICIAL FEEDING 



may be obtained. This state of affairs proves that there is no single method 
which outranks all others. The object of all these methods is to give the 
physician certain rules of thumb by which he may make milk formulas con- 
taining definite percentages of protein, fat, carbohydrates, and salts. Nearly 
all of these methods of feeding are more or less complicated in that they are 
formulated upon the idea that very exact percentages of protein, fat, carbo- 
hydrates, and salts are necessary to obtain good results in infant feeding, and 
the complications of the various methods commonly defeat their very ob- 
jects, in that the average physician will not take the time or trouble to 
work out by them the exact percentages of the ingredients of a modified 
milk mixture. While there can be no objection to accurate percentages in 
infant feeding, yet the experience of the world has demonstrated that these 
accurate percentages are not absolutely necessary to success, and that on 
the whole infants thrive just as well upon a milk mixture which is intelli- 
gently modified so that protein, fat, carbohydrates, and salts are found in 
fairly definite percentages and in such quantities that the infant will not 
suffer from a starvation of any one of these important ingredients. Largely 
as a result of the complicated methods now in vogue, most physicians com- 
monly use whole milk and some diluent in the form of a carbohydrate food, 
and upon these simple mixtures the large percentage of our infantile popu- 
lation is now thriving. While the simplicity of the "whole milk" method 
of modifying food has made it popular, there is no question but that much 
better results can be obtained by a method which utilizes top milk as well 
as whole milk in the preparation of infant foods, in that in this way the 



26 
25 
24 
23 
22 
21 
20 
19 
18 

CO '7 
Q 16 

i» 

OI4 

* 13 

12 

II 

10 
9 
8 
7 
6 
5 











































































































































































































































































































































































































































































































































































































































/ 
















































y 














































/ 
















































/ 























































































































































































































































































































































AGE IN WEEKS 
Fig. 21. — Weight Chart of Artificially Fed Infant. 

fat percentages may be better adapted to the nutritional demands of the 
infant. 

Percentage feeding may be greatly simplified and its efficacy, as I be- 



HOME MODIFICATION OF MILK 



137 



lieve, not materially diminished by making all food formulas from three 
ingredients, viz. : 

I. Whole milk, which to simplify computations one may assume con- 
tains 4 per cent, of fat, 4 per cent, of protein, and 4 per cent, of carbohy- 
drate. 

II. Top milk containing 7 per cent, cream, obtained by taking the top 
half of the milk after it has stood for two hours. This contains approxi- 
mately 7 per cent, fat, 4 per cent, protein, and 4 per cent carbohydrate. 

III. A carbohydrate solution made of sugars or starches containing 
one-half ounce of carbohydrate to the pint. 

In infants under six months of age, because of the greater dilution of 
the milk, the 7 per cent, top milk should be used, so as not to get too low 
percentages of fat. In infants over six months of age whole milk may be 
used. 

In making modified milk mixtures from these ingredients the physi- 
cian should be guided by "the principles underlying the artificial feeding of 
infants," previously outlined. The following tables show how these ingre- 
dients may be combined in the production of an infant food which will 
answer all practical purposes, that is to say, will possess the proper number 
of calories, will contain the important ingredients, proteins, fat, and car- 
bohydrates in such relative and absolute quantities that the nutritional and 
digestive demands of the infant will be satisfied quite as well as by more 
complicated mixtures in which the percentages of protein, fat, and carbo- 
hydrates are worked out to the fraction of a per cent. 

Between the eighth and the twelfth month the food of the average well 
infant outlined in this table is to be supplemented by the addition of orange 
juice, raw egg albumin, thick cereal gruels, meat juice, and meat broths 
with a cereal admixture, but these foods, with the exception of orange 

7 Per Cent. Top Milk Table 











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to 

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a 

02 


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s 

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d 

03 

bO 

a 
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1 

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a 

>> 

d 

3 

1 

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i 

4! 

"o 

ja 


a 
o> 
O 

i 

a 


"o 

m 

o 

(-T 

c3 
bO 

3 

M 
1 


Boiled Water, Ozs. of 


03 

S3 

o 

V 

"5 

I 

13 


o> 
bO 

3 


d 

'5 
o 
Ph 

"3 

o> 
bO 

cS 

d 

53 

(-. 


>> 

O 

■s 

o 

"o 

o 
bO 

ci 

3 
01 

o 

M 


2 

3 

.2 

OQ 

V 

•c 

o 
"3 
O 


-3 

SI 

'3 
o> 

1 
o 
"3 
O 


lWk.. 


7.5 


2 


2 


10 


20 




6 


1 


13 


l 


2 


i 


6 


306 


300 


2 Wks.. 


7.5 


2 


2 


10 


20 




6 


1 


13 


l 


2 


i 


6 


306 


300 


3 Wks.. 


8.0 


2V 2 


2 


9 


22^ 




6^ 


1 


15 


l 


2 


i.i 


5.6 


321 


320 


4 Wks. . 


8.5 


3 


2V 2 


8 


24 




7 




16 


1 


2 


l.i 


5.7 


352 


340 


2 Mo. . 


10.75 


4 


3 


7 


28 




9 


18 


l 


2.2 


1.3 


5.5 


429 


430 


3 Mo. . 


12.50 


5 


3 


7 


35 




10H 


IH 


23H 


l 


2.1 


1.2 


5.5 


505 


500 


4 Mo. . 


14 


5 


3 


7 


35 




11H 


1% 


22^ 


l 


2.3 


1.3 


6.4 


565 


560 


5 Mo. . 


15 


6 


3M 


6 


36 




13 


\% 


22 


l 


2.5 


1.5 


6.5 


603 


600 


6 Mo. . 


16 


QV 2 


sy 2 


6 


39 




15 


U4 


23 


l 


2.7 


1.5 


5.5 


645 


640 



138 



ARTIFICIAL FEEDING 
Whole Milk Table 











5 

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3 


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a 


a 

01 

01 

a 


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. (-1 

i 

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a 
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o 

u 
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1 
a 

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o> 

1 


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o 

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Pi 


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u 
3 
M 

i 

o 

o 


o> 

hi 

'3 

O" 
o> 

Pi 

01 

0> 
| 

"3 
O 


1 Wk. . . . 


7.5 


2 


2 


10 


20 


7 




1M 


12 




1.4 


1.4 


7.5 


307 


300 


2Wks... 


7.5 


2 


2 


10 


20 


7 




1M 


12 




1.4 


1.4 


7.5 


307 


300 


3 Wks... 


8 


23^ 


2 


9 


22J^ 


8 




1M 


13H 




1.4 


1.4 


7 


318 


320 


4 Wks. . . 


8.5 


3 


2H 


8 


24 


9 




1M 


14 




1.5 


1.5 


6.5 


339 


340 


2 Mo.... 


10.75 


4 


3 


7 


28 


14 




1M 


13 




2 


2 


6 


444 


430 


3 Mo.... 


12.50 


5 


3 


7 


35 


19 






16 




2.2 


2.2 


5.2 


519 


500 


4 Mo.... 


14 


5 


3 


7 


35 


21 




i 


13 




2.5 


2.5 


5.5 


560 


560 


5 Mo.... 


15 


6 


3H 


6 


36 


23 




i 


11 




2.6 


2.6 


5.5 


603 


600 


6 Mo.... 


16 


6^ 


sy 2 


6 


39 


25 




l 


13 




2.6 


2.6 


5.3 


645 


640 


7 Mo.... 


16.75 


8 


4 


5 


40 


27 




l 


13 




2.6 


2.6 


5.1 


687 


670 


8 Mo.... 


17.50 


8 


4 


5 


40 


28 




l 


12 




2.8 


2.8 


5.3 


708 


700 


9 Mo.... 


18.25 


8 


4 


5 


40 


29 




l 


10 




2.9 


2.9 


5.4 


729 


730 


10 Mo.... 


19 


8 


4 


5 


40 


32 




H 


7 




3.2 


3.2 


5.1 


760 


760 


11 Mo.... 


20 


10 


4 


4 


40 


35 




y* 


4 




3.5 


3.5 


4.75 


800 


800 


12 Mo.... 


21 


10 


4 


4 


40 


40 













4 


4 


4 


840 


840 



juice, should always precede or follow the bottle, which remains the chief 
part of the meal. 

It may be noted by a glance at the whole-milk table that the fat per- 
centages are somewhat lower and the protein and carbohydrate percentages 
somewhat higher than is commonly recommended by American authors. 
These changes from the routine formulas, however, are not objectionable, 
since they make the food more easily digested. The diminished amount of 
fat, which is rather difficult of digestion for the average infant, is made up 
by the increase in carbohydrates, which are very easily digested, and both of 
these changes facilitate protein digestion. The object of the table is to 
offer a method so simple that the busy physician can hold it in his mind 
and by it make modified milk mixtures which conform both to the per- 
centage method and caloric standard. 

Carbohydrate Diluents. — The carbohydrates in these milk formulas may 
be changed at the will of the physician, and in doing so it should be remem- 
bered that all carbohydrates used in infant feeding have practically the 
same food value. One ounce of milk sugar has the same caloric value as 
1 ounce of cane sugar, wheat flour, barley flour, or oatmeal, and in making 
the carbohydrate diluent of an infant food they should all be used in the 
proportion of one-half ounce to the pint of water. In very young infants 
it is perhaps better to use dextrinized gruels made from barley or wheat. 
In older infants (after the third or fourth month) the unchanged cereal 
gruels made from barley, wheat, and oats answer quite as well as those which 
have been dextrinized. The carbohydrate diluents facilitate the digestion of 
protein. This action is perhaps purely mechanical in that the casein of 



HOME MODIFICATION OF MILK 139 

milk, when surrounded by a carbohydrate mixture, is precipitated in finer 
flocculae and large curd formation is prevented. 

Alkaline Diluents. — Experience has taught that the addition of alka- 
lies to modified milk mixtures facilitates their digestion. The alkalies in 
most common use are lime water and bicarbonate of soda. The alkalies 
facilitate the digestion of casein by inhibiting the action of the rennet 
ferment, delaying the coagulation of casein and neutralizing the fermenta- 
tion acids. Of the two alkaline diluents, lime water and bicarbonate of 
soda, lime water is more commonly used. It has the same action as the 
soda in preventing tough curd formation and acts more powerfully in 
stimulating the secretion of hydrochloric acid. Lime water should be used 
in the strength of 1 or 2 ounces to every 20 ounces of food, and bicarbonate 
of soda, 1 grain for every ounce of food. Chlorid of soda may be used 
instead of the bicarbonate in the same strength. If alkalies are used in too 
large quantities all action in the stomach on casein is suspended, and it 
passes uncoagulated into the small intestine. If this action of the alkalies 
is desired to prevent the coagulation of the milk in the stomach, 2 to 2% 
grains of bicarbonate of soda should be used for each ounce of food. Citrate 
of soda is not an alkali, but when added to milk it decalcifies the casein, 
and prevents the action of the rennet. This decalcified casein forms with 
hydrochloric acid soft, friable flakes, in this way preventing the formation 
of tough curds. It may therefore be of considerable value in promoting 
the digestion of milk when there is a tendency to tough curd formation. 
One grain of sodium citrate for each ounce of milk in the food will insure 
the formation of soft curds instead of tough ones. 

Determination of Accurate Percentages. — For those who desire to use 
food formulas in which the percentages of the important ingredients are 
more accurately determined, the following table, adapted by Southworth 
from that of J. F. Connors is given on page 140. 

Southworth says: "The proteids have been calculated upon the basis 
of both 4 per cent, and 3.50 per cent. The former, 4 per cent., is for 
those who use round numbers to facilitate mental calculation of percent- 
ages. The latter, 3.50 per cent., which is the actual percentage of proteids 
in good average milk having 4 per cent, fat, is to enable the practitioner 
to determine readily the more exact amount of proteids in any given mix- 
ture. Either column may be used for the purpose of making a mixture of 
any desired percentages or in determining the percentages contained in any 
mixture of known proportions. To make up any desired percentage mix- 
ture (1) find in the one of the proteid columns determined upon the de- 
sired percentage, or that which is nearest it; (2) move in a horizontal line 
to the right until the desired percentage of fat is reached, or one which is 
nearest to it; (3) the heading of this fat column tells what kind of milk 
is to be used; (4) on the same line with the fat percentage at the right 
will be found the fraction showing the necessary proportions of this milk 
or top milk in the food mixtures to give the percentages selected, and be- 
yond this will be found the number of parts of such milk or top milk and 



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EOTCH LABORATOBY METHOD OF MODIFYING MILK 141 

of diluent which must be used; (5) dip off the proper milk and dilute all 
or a part of it, depending on the quantity of the food to be made up; (6) 
the addition of 2% fairly level tablespoonfuls of milk-sugar or 2 exactly 
level tablespoonfuls of granulated sugar for about every 20 ounces of the 
total mixture will give the proper percentages of sugar/"' 

THE ROTCH LABORATORY METHOD OF MODIFYING MILK 

The world owes to T. M. Kotch, of Boston, a lasting debt of gratitude 
for the work he has done in outlining, establishing, and popularizing per- 
centage feeding. In accomplishing this work he has used as his agents the 
Walker-Gordon Milk Laboratories. These laboratories have the following 
stock supplies : 

1. A 32-per-cent. fat cream mixture. 

2. Separated milk which is almost fat-free. 

3. A 20-per-cent. solution of milk sugar. Other sugars such as mal- 
tose, sucrose, and dextrose may be prescribed. 

4. Whey. 

5. Cereal decoctions. 

6. Lime water and other alkalies used in modifying milk. 

From these supplies the physician may prescribe a milk mixture calling 
for specified percentages of fat, protein, carbohydrates, and alkalies, desig- 
nate the amount in ounces for each feeding and the number of feedings in 
twenty-four hours. The whole supply to be delivered each morning in a 
neat, clean box with compartments for holding the individual bottles and 
each bottle containing the amount of the mixture prescribed for a single 
nursing. The nurse or mother has only to warm the milk mixture by 
placing the bottle in warm water and then, on taking out the cotton stop- 
per and slipping a nipple over the mouth of the bottle, it is ready for the 
baby to take. 

The milk laboratories under- the Walker-Gordon management are as re- 
liable as milk laboratories can be made. The stock materials from which 
the modified milk is compounded are as clean and wholesome as scientific 
methods can make them. And the compounding is done with such accuracy 
that the physician may rely upon getting the percentages of the various 
ingredients as he has ordered them. 

The following is a typical laboratory prescription: 

Per Cent. Eemarks 



J$ Fats 3.00 

Milk sugar 6.00 

Protein total 1.00 

" (whey) 0.75 

" (casein) 0.25 



Number of feedings 9 

Amount at each feeding. . .3 ounces 

Infant 's age 1 month 

Infant 's weight 9 pounds 

Alkalinity, lime water 5 per cent. 

Heat at 150° F 



If the original formula prescribed for the baby does not agree with it, 
or does not meet its nutritional demands, any one or all of the various 



142 AETIFICIAL FEEDING 

ingredients may be changed at the will of the physician by simply writing 
a new prescription. The laboratory method of percentage feeding is the 
simplest and most accurate. The expense, however, of thirty to forty cents 
a day which it entails, and the location of these laboratories in only a few 
of our largest cities shut out the vast majority of infants from the advan- 
tages which this method offers. 

ADDITION TO DIET OF BOTTLE-FED INFANTS 
AND CHILDREN 

Foods Added in the First Twelve Months of Infancy. — The exact time 
at which other food shall be added to the diet of the bottle-fed infant de- 
pends altogether upon the digestive capacity of the individual, and what is 
here said applies to the average normal infant. Of course delicate infants 
of the same age will have to be placed upon a diet suitable to an infant 
several months younger; and strong, sturdy infants of unusual physical 
development may be able to take food which in the average is suitable for 
children several months older. 

Orange juice is one of the most valuable of infant foods and is almost 
indispensable when the infant is fed upon sterilized foods. Under these 
conditions it prevents scurvy and overcomes constipation. It may be added 
to the diet at the eighth month. The juice of half an orange is to be given 
daily between feedings. At the end of the first year the quantity may be 
increased to a whole orange. 

Meat juice is also a valuable food which may be begun as early as the 
eighth or ninth month, one ounce twice a day with a bottle feeding. Both 
the orange and the meat juice remain as staple articles of the infant's and 
child's diet for two or three years. 

Foods Added to the Diet from the Twelfth to the Eighteenth Month. 
— Cereals, covered with clean milk and sugar or salt, may be begun at the 
end of the first year. A tablespoonful of well-cooked cereal, followed by 
six ounces of milk, making one of the meals. The following cereals are 
recommended : Oatmeal, cream of wheat, wheatena, and rice. In the be- 
ginning not more than one cereal feeding should be given in a day. Broths 
made from beef, lamb, or chicken and slightly thickened with one of the 
cereals may next be added to the diet; not more than six ounces of broth 
should be given and this should be followed by a six-ounce bottle, making 
a meal. Fresh, soft-boiled eggs are perhaps the most valuable addition to 
the infant's diet at this time. They are easily digested and in the begin- 
ning it may be wise to alternate with the cereals, giving an egg every second 
or every third day. The white of the egg mixed with eight ounces of water 
is a food that may be used even during the first year of life. Bread, toast, 
rusk, and crackers, softened with milk, may be given as a part of one of 
the meals at this time. 

The normal infant from fifteen to eighteen months of age should have 
five feedings daily, and four of these feedings should be supplemented as 



ADDITION TO DIET 143 

follows : A cereal with the first meal, broth with the second, egg with the 
third, bread or toast with the fourth, and following each of these a six- 
ounce bottle of whole milk. The orange juice still remains a part of the 
diet. 

Foods Added from the Eighteenth to the Twenty-fourth Month. — Prune 
juice or apple sauce may be added to the six-o'clock meal at this time. 
Potato, baked, or boiled and mashed, may now alternate with the cereals. 
Beef balls made by broiling scraped beef may alternate with the egg and 
later take the place of the broth. During this period the ten-o'clock feed- 
ing is discontinued and the child has but four feedings a day. 

Foods Added during the Third Year. — Fresh vegetables such as aspar- 
agus tips, peas, string beans, stewed celery, and spinach are now a part of 
the child's diet. One of these may be given each day. Desserts such as 
rice pudding, bread pudding, baked custard, junket, and ice cream made 
from clean milk may be gradually added to the child's diet; ice cream, 
however, should not be given more than once or twice a week and then 
only toward the end of the third year. Eaw fruits, such as peaches, apples, 
pears, and grapes, may now occasionally take the place of apple sauce or 
orange juice. Meats, such as lamb chops, chicken, fish, or beef, may be 
minced and moistened with beef juice or broth and given once a day. 
Breads of various kinds, such as corn bread and dry cold biscuits, are now 
wholesome articles of food. By the end of the third year the child should 
have but three meals a day. 

From the Fourth to the Sixth Year. — From the fourth to the sixth 
year the following foods should be excluded from the child's diet. Tea, 
coffee and alcoholic drinks, pastry, nuts and sweets, except very simple 
cakes and an occasional piece of good candy, pork, preserved meats, raw 
vegetables, salads, griddle cakes, and fried food of all kinds. 

From the above diet list it will be easy to prescribe a diet suitable to the 
age of the child. But throughout all of this time it is most important that 
milk should remain the basis of the child's diet and care should be taken 
that it should not be overfed. There is little or no danger in underfeeding 
the normal child. 



11 



SECTION IV 

DISEASES OF DIGESTIVE SYSTEM 
CHAPTEE XV 

DENTITION 

THE TEMPORARY TEETH 

Eruption of the Temporary Teeth. — The mouth of the infant for the 
first six or eight months of life contains no teeth. The absence of teeth at 
this time serves a wise purpose in that the infant can better perform the 
act of sucking. The formation of the temporary teeth begins in early fetal 
life and continues until at birth they are inclosed in membranous tooth 
sacs, more or less deeply imbedded in the alveolar processes of the jaws, 
covered only by the submucous connective tissue and the mucous membrane. 
The temporary teeth are twenty in number, and at birth the dental sacs 
which hold them rest upon the sacs of the permanent teeth. The erujotion 
of the temporary teeth through the gums begins between the sixth and the 
eighth month and is usually not completed until in the early months of 
the third year of life. These teeth usually make their appearance in crops 
or groups of two or four, followed by a six or eight weeks' interval of rest. 
The eruption of the temporary teeth, on the whole, follows a definite order 
which may vary even in well infants, but these variations are greatly exag- 
gerated in rachitic, syphilitic, and otherwise malnourished infants. On the 
whole, the teeth come through earlier and conform more closely to the 
regular order of eruption in the breast-fed than in the artificially nourished 
infant. The following table shows the usual order and the average time 
of eruption of the different groups of teeth. These variations are within 
normal physiological limits : 

Two lower central incisors 6 to 8 months 

Two upper central incisors 8 to 12 months 

Two upper lateral incisors 9 to 12 months 

Two lower lateral incisors 12 to 15 months 

Four anterior molars 13 to 16 months 

Four canines 18 to 22 months 

Four posterior molars 22 to 30 months 

When one year of age an infant should have six teeth; when one and 
one-half years of age, ten or twelve teeth; when two years of age, sixteen 

144 



THE TEMPORARY TEETH 145 

teeth ; when two and one-half years of age, twenty teeth. In rare instances 
infants may be born with teeth; when this occurs it is almost always the 
lower central incisors that are present. This congenital anomaly is of 
little pathological importance. In many instances these teeth are set so 
loosely in the gums that they act as an irritant and interfere with nursing ; 
when this is the case they should be removed. When, however, they are 
firmly set in their alveolar processes they should be let alone ; their presence 
causes neither the infant nor the mother any inconvenience and their re- 
moval deprives the infant of just so many temporary teeth. 

Delayed Dentition. — Rickets and other forms of malnutrition are the 
common causes of delayed dentition, but heredity may also be a factor. If 
no teeth have appeared by the end of the first year of life, rickets should 
be suspected and other symptoms of this disease sought for. The same 
causes which delay dentition predispose to irregularities in the time of 
eruption of the various groups ; for example, the upper incisors may appear 
before the lower and the canines before the molars. In malnourished chil- 
dren the teeth not only come in late and irregularly, but they are poorly 
developed, imperfectly formed, and decay early. 

Dentition as a Pathological Factor.- — At one time in the history of 
medicine almost all the ills of infancy and early childhood which occurred 
during teething were attributed in a greater or less degree to dentition. 
At that time it was believed to be the all-important cause of gastrointestinal 
disturbances and of functional nervous disorders. Diarrhea, enteritis, sleep- 
lessness, general nervous irritability, convulsions, running ears, and even 
diseases of the respiratory passages were attributed to dentition. In recent 
years, as the causes of diarrheal, nervous, and other diseases in infancy have 
been more carefully worked out, dentition has gradually lost its importance 
as a pathological factor. The teachings of Forchheimer played no little 
part in this reaction. He strongly maintained that dentition rarely played 
any role either in producing or aggravating pathological processes, and 
taught that "teething produces teeth and nothing more/*' While Forch- 
heimer recognized that certain slight and evanescent symptoms might be 
due to teething, he held that the safety and welfare of the infant, during 
this period, largely depended upon the clinician disregarding dentition as 
a pathological factor and searching for other remedial causes of the in- 
fant's illness. However, it is important that we should not altogether for- 
get that teething is not infrequently accompanied by pain and by certain 
symptoms on the part of the nervous system and gastrointestinal tract. In 
a perfectly normal breast-fed infant a tooth may come through without 
producing any symptoms whatever; the first evidence of its eruption may 
be the finding of its tiny point, which has pierced the gum over-night, but 
this is not usually the case even in normal infants. The most common 
symptoms due to teething are swelling, redness and tenderness of the gums, 
increased flow of saliva, sleeplessness, marked restlessness, increased nerv- 
ous irritability, exaggerated reflex excitability, elevation of temperature, 
refusal to take food, regurgitation of food, vomiting, intestinal indigestion, 



146 STOMATITIS 

and slight looseness of the bowels. In rachitic and malnourished infants 
these symptoms are so much more marked that one might almost say that 
their severity is largely dependent upon the degree of malnutrition from 
which the infant is suffering. 

Care of the Teeth.- — It is rarely if ever necessary to lance the gum to 
relieve the symptoms which are believed to be associated with difficult den- 
tition. The majority of pediatricians never find it necessary to make this 
operation. It is important to take proper care of the temporary teeth, since 
they serve the purpose of preserving the shape of the jaw and making 
second dentition more normal and less difficult; they are to be kept clean 
by washing the mouth once or twice a day with lukewarm water, or with 
a weak boracic solution. Particles of food materials must not be allowed 
to collect between the teeth or at their roots, and thus furnish a culture 
field for pathogenic microorganisms. 

THE PERMANENT TEETH 

Permanent teeth are thirty-two in number. The first molars, which 
appear earliest, penetrate the gum about the sixth or seventh year. Forch- 
heimer's table, which follows, gives the time of the appearance of the sec- 
ond set of teeth. 

First molars 6 years 

Incisors 7 to 8 years 

Bicuspids 9 to 10 years 

Canines 12 to 14 years 

Second molars 12 to 15 years 

Third molars 17 to 25 years 

Malnutrition of a pronounced type may delay and interfere with second 
dentition just as it does with first dentition. In congenital syphilis the 
second teeth are poorly formed, decay early and in some instances the upper 
central incisors show a characteristic deformity known as Hutchinson's 
teeth. This condition is described under Congenital Syphilis. In neurotic 
malnourished children the eruption of the second teeth may act as a reflex 
factor in the production of nervous symptoms and digestive disturbances 
somewhat less severe than the symptom group produced by the first den- 
tition. 

CHAPTEE XVI 
STOMATITIS 

STOMATITIS CATARRHALIS 

Symptomatology. — Stomatitis catarrhalis is a simple inflammation of 
the mucous membrane of the mouth. It usually begins on the gums or 
tongue and spreads to involve the entire mucous membrane of the mouth. 
It is characterized by redness and swelling of this membrane, and by an 



STOMATITIS APHTHOSA 147 

increasing salivary and mucous secretion. When the disease is well estab- 
lished the mucous membrane is intensely congested and slight hemorrhages 
may occur. The gums are usually much swollen, and this may extend to 
the lips, causing a decided thickening. The pain and irritation cause the 
infant to be fretful, sleepless, and to refuse food. The act of sucking ap- 
parently causes pain. The salivary glands are excited to increased activity, 
so that the saliva flows out of the mouth, wetting the face and clothing. 
Forchheimer calls attention to the enlargement of the muciparous follicles 
which appear as small, round prominences on the red mucous membrane, 
and to the fact that in older infants the swollen tongue and cheeks show 
the indentations of the teeth. The temperature is normal or slightly ele- 
vated. The lymph nodes are not enlarged. The infant's general nutrition 
may suffer slightly because of the lack of food and general nervous irrita- 
bility. When constitutional symptoms are marked the catarrhal stomatitis 
is then a symptom of some acute toxic condition. 

Etiology. — This condition is most common during the first year of life. 
It is produced by some mechanical, chemical, toxic or thermal injury to the 
mucous membrane (Forchheimer). The introduction of foreign bodies, 
carelessness or roughness in washing the mouth, strong acids or alkalies, 
dirt, decomposing food, pacifiers, and hot and cold food are among the com- 
mon exciting causes. Catarrhal stomatitis is usually present in most of the 
acute infectious diseases. 

Treatment. — The disease runs a benign course and terminates in recov- 
ery within five or six days, provided the mouth is kept clean and the excit- 
ing cause is removed. The mouth may be washed with a 2 or 3 per 
cent, solution of boracic acid or with a mild alkaline antiseptic. A laxative 
should be given, preferably castor oil, and the milk, if the infant be arti- 
ficially fed, should be diluted with barley water; cool food is more readily 
taken. It is, as a rule, bad practice to attempt to force food in these cases ; 
in some instances, however, the modified milk mixture will be taken readily 
with a spoon even after the infant has refused to nurse. Weak solutions of 
some astringent, such as a one-half per cent, solution of nitrate of silver, is 
recommended in those cases where for any reason the disease is prolonged 
beyond a week. 

STOMATITIS APHTHOSA 

Etiology. — The causes of this condition are not definitely known. It 
has been suggested that it is brought about by intestinal or other toxins; 
that it is of neurotic origin; that it is a local infection due to pathogenic 
microorganisms and associated with uncleanliness and fermenting food 
material in the mouth. It is sometimes associated with the acute infectious 
diseases and with severe disturbances of the gastrointestinal canal. 

Symptomatology. — This condition has been described under the name 
herpetic stomatitis, maculofibrinous stomatitis, vesicular stomatitis and fol- 
licular stomatitis. It is characterized by the appearance of superficial 
ulcers, scattered widely over the soft palate, hard palate, gums, tongue, and 



148 STOMATITIS 

the inner surface of the lips and cheek. These ulcers appear as yellowish- 
white spots, covered with a fibroplastic exudate and surrounded by an area 
of congested, swollen and reddened mucous membrane. There may be 
only a few of these ulcers present, or the whole mucous membrane of the 
mouth may be dotted with them. These small, round, yellowish-white 
ulcers, from one-eighth to one-fourth of an inch in diameter, present a very 
characteristic appearance. If near together they may coalesce to form 
larger, irregular ulcers. The catarrhal stomatitis, which is always asso- 
ciated with this condition, is more intense in the immediate vicinity of the 
ulcers. There is great increase in the salivary flow, and drooling is always 
present. The pain is very intense and is greatly aggravated by any irri- 
tating material coming in contact with the ulcers. For this reason infants 
suffering from this condition may abstain almost absolutely from food for 
two or three days at a time, and a paroxysm of crying and nervous irrita- 
bility may be provoked by any attempt at feeding. This condition occurs 
most commonly during the second year of life, so that children suffering 
from it can usually be induced to take water or some non-irritating food 
such as milk or barley water from a spoon when they absolutely refuse to 
take it from a nursing bottle. Not infrequently gastrointestinal disturb- 
ances are associated with this form of stomatitis. 

Prognosis. — This disease runs a benign course and terminates in re- 
covery within a week or ten days. 

Treatment. — This should be begun with a dose of castor oil, to be fol- 
lowed by a very bland diet. Irritating food, such as broths and meat juice 
which contain salt, cause pain and are refused. Cool water and cow's milk 
diluted with barley water should be given to the child to drink or should 
be fed with a spoon. The mouth should be washed with mild alkaline non- 
irritating antiseptics; a weak solution of boracic acid may be used for this 
purpose. 

STOMATITIS MYCOSA 

(Sprue; Thrush) 

Etiology. — Thrush is produced by a specific fungus which, under the 
microscope, presents the appearance of fine, tangled, jointed filaments. 
These slender threads are composed of rods with spores at their ends, and 
scattered through the tangled threads isolated spores and epithelial cells 
are seen. These fungi, as Forchheimer has taught, penetrate beneath the 
epithelial layers, lifting and separating them; in this way the disease 
spreads along the surface and. into the deeper layers of the mucous mem- 
brane and in rare instances invades the underlying tissues and distant 
organs. It most commonly attacks the mucous membrane of the cheeks, 
hard palate and tongue; other portions of the mouth are not uncommonly 
involved, and much more rarely the pharynx, stomach and intestines are 
attacked by this fungus. It occurs most commonly during the first three 
months of life among infants whose surroundings are dirty and unhygienic 



STOMATITIS MYCOSA 



149 






and who are improperly fed and neglected. Catarrhal stomatitis usually 
precedes thrush and prepares the mucous membrane for inoculation with 
the fungus of this disease. All the exciting factors of catarrhal stomatitis 
become, therefore, the predisposing factors of thrush. This disease is very 
much more common in malnourished, marasmic infants and is therefore 
more prevalent in hospital and dispensary practice. The contagion is very 
widespread; it may be found on the buccal mucous membranes of healthy 
infants. This impresses the fact that susceptibility to this disease is an 
important etiological factor. Normal mucous membranes are capable of 
resisting it, but diseased and injured mucous membranes furnish a favor- 
able soil for its growth. General lack of resistance, associated with profound 
malnutrition, is also an important factor, not only in starting the growth, 
but in facilitating its spread. 

Symptomatology. — This disease is readily recognized by the appearance 
on the tongue, cheeks or other portions of the mouth of small, white 
patches which resemble coagulated milk. These white masses seem to be 
loosely attached, but on attempting to remove them they are found to cling 
closely and to be imbedded in the mucous membrane ; their removal leaves 
raw and bleeding surfaces; by this fact they are easily differentiated from 
milk curds. As they increase in size they coalesce and form larger irregular 
patches, and in aggravated cases may cover a large portion of the buccal 
mucous membrane. A slight catarrhal stomatitis is usually present. The 
secretions of the mouth take on an acid reaction due to the fermentation 
produced by this fungus. There may be more or less difficulty in swallow- 
ing and pain on taking food, which causes the infant to refuse nourishment. 
This may become a serious fea- 



ture of the disease when it occurs 
as a complication of severe mal- 
nutrition, and may in the maras- 
mic infant hasten or cause a fatal 
termination. Uncomplicated 
thrush, however, is not a serious 
disease; it runs its course and 
terminates in recovery within a 
week. When associated with se- 
vere constitutional disorders, 
however, the disease may persist 
an indefinite length of time, and 
recurrences in these cases are not 
uncommon. In rare instances FlG - 22 

tonsillar or pharyngeal thrush a ' mycelium; b spores; c epithelial cells from the 
_ * n t i mouth; d, leukocytes; e, detritus. (V. Jaksch.) 

may somewhat resemble diph- 
theria, but the age of the infant, the absence of constitutional symptoms, 
and, finally, a microscopical examination which reveals the thrush fungus 
will readily make the differential diagnosis. 

Treatment. — The prophylactic treatment of thrush has greatly diinin- 




-Thrush Fungus (Highly Magnified) . 



150 STOMATITIS 

ished its prevalence in recent years. If the infant is properly cared for 
and is given clean food through clean nipples and is protected in other 
ways from the introduction of filth and dirt into its mouth, thrush will 
rarely occur. The tendency at the present time is to overdo in the matter 
of mouth-washing in the healthy infant. Whatever mouth-washing is done 
during the first few months of life should not only be done with sterile 
washes and soft sterile cloths, but it should be done gently so as not to 
injure the buccal mucous membrane. Pacifiers, dirty toys and other un- 
clean things should be kept out of the infant's mouth, and above all it should 
be fed carefully along the lines outlined under Infant Feeding. 

In the treatment of thrush a dose of castor oil should be given, and 
thereafter the child should be carefully fed as above indicated. Gastro- 
intestinal disorders and the underlying malnutrition, if such exist, should 
be given appropriate treatment. If the infant is breast-fed, the mother's 
nipple, before and after nursing, should be carefully cleansed. If it refuses 
food it may sometimes be necessary to use gavage ; in most instances, how- 
ever, the infant may be fed with a spoon or with a medicine dropper. 

The local treatment of this condition is simple. The patches should 
be gently brushed or wiped with cotton or a soft cloth saturated with a mild 
alkaline antiseptic; a 2 per cent, solution of boric acid and bicarbonate of 
soda serves this purpose well. In order to remove the patches quickly this 
brushing should be done three or four times a day; care should be taken, 
however, not to injure the mucous membrane by forcibly tearing the patch 
away. Stronger applications, such as a 1 per cent, nitrate of silver solu- 
tion, may be gently applied once a day in those cases where the thrush 
does not yield readily to the boric acid treatment. Following the use of 
boric acid or nitrate of silver the mouth should be washed with sterile water. 

STOMATITIS ULCEROSA 

Etiology. — The specific cause of this disease is not definitely known, but 
the distinct clinical picture which it presents indicates that it is due to 
some specific microorganism. Bernheim and Pospischill, in a series of 
cases, isolated a bacillus probably identical with that of Vincent, which was 
always associated with a spirochete, and they apparently demonstrated that 
ulcerative stomatitis could be produced by these microorganisms. The fact, 
however, that these microorganisms are also associated with mercurial sto- 
matitis, with various forms of gangrene and suppurative diseases about the 
mouth, together with the fact that in ulcerative stomatitis, streptococci, 
staphylococci, and other pus formers play an important role in the de- 
structive process, indicates that the etiological relationship of the Vincent 
bacillus to stomatitis ulcerosa has not been definitely proven. This disease 
occurs most commonly in malnourished children having decayed or dis- 
eased teeth, which irritate and mutilate the gums and furnish a nest for 
decomposing food material. Improper food, uncleanliness of the food 
utensils and everything that facilitates the carrying, of dirt and micro- 



STOMATITIS ULCEROSA 151 

organisms into the child's mouth may be etiological factors. This disease 
is much more common in hospital and dispensary practice. 

Ulcerative stomatitis also occurs as a symptom of scurvy and of mer- 
curial and other metallic poisonings. 

Symptomatology. — The offensive breath and profuse salivation are the 
symptoms which commonly call attention to this disease, and an examina- 
tion of the mouth reveals in the early stage an intense redness and swelling 
of the gums, usually along the incisor teeth. The swelling and redness 
become more marked, the gum separates slightly from the tooth and a 
yellowish ulcer appears on its edge. As the disease progresses the ulcera- 
tion spreads and extends to the buccal mucous membrane which is opposed 
to the ulcer. The extent of the ulceration on the two opposed mucous 
membranes corresponds very closely. As the ulceration proceeds the gum 
becomes more and more separated from the teeth, which may be loosened 
and sometimes may be lost. The ulcerated mucous membrane is very tender, 
bleeds on the slightest touch, and causes great discomfort, especially when 
food is taken. The offensive breath becomes more fetid, the saliva pours 
from the mouth, and the large ulcer, which has resulted in considerable loss 
of tissue, both on the gum and the opposed mucous membrane of the lips 
or cheeks, is covered with a yellowish, purulent exudate. In rare instances 
the alveolar processes may be involved and necrosis of bone may occur. 
The anterior cervical lymphatic glands are swollen and tender. The tongue 
is covered with a thick, brownish coat. There are no constitutional symp- 
toms produced by this disease; when fever and other general symptoms 
are present they are due to a coexisting or complicating affection. 

The course of the disease is usually benign and recovery may be ex- 
pected within a week or ten days. When, however, this condition occurs 
as a complication of severe malnutrition it does not yield so readily to 
treatment. 

Treatment. — The preventive treatment is the same as that given for 
thrush. The local treatment consists in the careful washing of the ulcer 
with some mild alkaline antiseptic : a 2 per cent, boracic acid and bicar- 
bonate of soda solution may be used for this purpose. The ulcer should 
not be irritated by the application of strong astringents or by brushing it 
roughly with cloth or cotton for the purpose of applying a cleansing solu- 
tion; if it is carefully exposed, gentle irrigation is all that is necessary 
for purposes of cleanliness. 

Chlorate of potash is the all-important remedy in the treatment of this 
disease; it is believed by Forchheimer and others to act specifically in its 
cure. One or two grains of chlorate of potash, depending upon the age of 
the child, is to be given, well diluted, every hour or two during the waking 
period for two or three days ; thereafter, if necessary, it should be given at 
longer intervals. A solution of chlorate of potash should also be used at 
intervals during the day for irrigating the ulcer. The chlorate of potash 
taken internally is largely excreted through the saliva, and in this way a 
more or less constant application of this drug to the diseased parts is pro- 



152 



STOMATITIS 



duced. Weak solutions of alum and nitrate of silver are also very generally 
recommended, especially in those cases that do not yield readily to treat- 
ment. In my experience these astringents are rarely, if ever, necessary. An 
important part of the treatment consists in inducing the child to take 
proper food, such as milk and cereal mixtures. 



STOMATITIS GANGRENOSA 

(Noma; Cancrum Oris) 

Etiology. — Noma is a severe infection most commonly beginning in the 
mucous membrane of the mouth and resulting in more or less extensive 
gangrene of the soft parts of the face ; its definite clinical history indicates 
that it is due to some specific cause. Babes and Zambolovici isolated a 
bacillus which they believe to be etiologically related to this disease, and 
the bacillus and spirillum of Vincent together with the ordinary pyogenic 





Fig. 23. — Stomatitis Gangrenosa, be- 
fore Perforation. 



Fig. 



24. — Stomatitis Gangrenosa, aft- 
er Perforation. 



organisms are associated with its destructive processes. Noma occurs most 
commonly between the second and the sixth year of life. It attacks children 
whose vital powers have been greatly reduced by serious illness. It may 
occur as a sequel of ulcerative stomatitis and is commonly seen as a com- 
plication of measles and, more rarely, of diphtheria, typhoid fever, scarlet 
fever and whooping-cough. Holt saw "five cases in a single ward, all be- 
ginning in the auditory canal, which were apparently produced by the use 
of the same syringe to clean the ears without proper disinfection. All of 
these children were suffering from whooping-cough at the time." 

Symptomatology. — A putrid odor may lead to the examination of the 



STOMATITIS GANGRENOSA 153 

mouth, and the diagnosis is made by the characteristic appearances there 
seen. On the inside of the cheek a dark, necrotic nicer, surrounded by an 
infiltrated and swollen area, may commonly be seen and felt, and the 
outer surface of the cheek is infiltrated, producing a hard lump, over 
which the skin may be pale and not at all sensitive to touch. As the infil- 
tration spreads a well-defined dark or black, gangrenous patch may be seen 
on the mucous membrane. The necrosis slowly spreads, the gangrenous 
process extends through the cheek, involving the skin. The line of de- 
marcation between the dead and the live tissue is now well marked. Per- 
foration of the cheek results from the dislodgment of the gangrenous patch, 
and through the opening the teeth or mucous membranes of the gums may 
be seen. Very commonly the gums are affected, and the bones beneath may 
become necrotic and the teeth may come out. There is little or no pain 
in this disease and hemorrhages are very unusual. Strangely enough the 
gangrenous process is almost always confined to one side of the face ; rarely 
both sides may be affected. As the disease progresses the fetor increases 
and the disagreeable odor is almost unbearable. In the beginning there is 
little to call attention to the serious character of the disease; the child 
may be playful, sit up in bed and take nourishment, but as the disease 
progresses a septic temperature becomes more marked. The fever may 
reach 104° or 105° F. The pulse becomes weak, prostration grows apace, 
and the child finally dies from exhaustion, or from some complication such 
as bronchopneumonia. 

Prognosis.- — The prognosis is very grave. The great majority of these 
cases die. Fifteen or twenty per cent, of them recover after prolonged ill- 
ness, and the resulting deformity is great. 

Treatment.' — There is little in the way of medical treatment beyond 
careful feeding and the use of whiskey, brandy and heart tonics to keep 
up the general strength of the child; the gangrenous parts should be kept 
as clean as possible by antiseptic washes. In a small percentage of the 
cases nature effects a cure. Diphtheria antitoxin has been used with some 
success in cases due to the Klebs-Loffler bacillus. In gangrene, following 
tonsillitis, antistreptococcic serum may do good. 

Noma should be classified as a surgical disease, and as soon as the 
diagnosis has been accurately established the case should be referred to a 
surgeon for treatment. Excision of the gangrenous part should be thorough ; 
the tissues should be removed well beyond the gangrenous line and all dis- 
eased bone taken out; the surgical wound thus made should be cauterized 
and thereafter dressed according to approved surgical methods. Under this 
treatment the chances for recovery are improved, but at best the condition 
is a desperate one and desperate chances should be taken to save life. 



154 DISEASES OF THE MOUTH AND ESOPHAGUS 



CHAPTEE XVII 

OTHEE DISEASES OF THE MOUTH AND DISEASES OF THE 

ESOPHAGUS 

BEDNAR'S APHTHiE 

This is a condition of little pathological importance. It consists of two 
small, rounded, grayish-white ulcers about the size of a pea, symmetrically 
located on the hamular processes of the palate bone, at an equal distance 
from the palatine ridge. They produce no constitutional symptoms, but are 
slightly painful to the touch and may therefore interfere with the taking 
of food. They are believed to be produced by some injury to the mucous 
membrane, which is especially prominent and delicate over the hamular 
processes. The exciting causes are too vigorous mouth-washing and the 
prolonged sucking of rubber nipples and pacifiers. This condition occurs 
only during the first weeks of life. 

Treatment. — The condition is a benign one and requires no treatment 
other than the irrigation of the mouth with sterile water or a 2 per cent, 
solution of boric acid. The ulcers are not to be rubbed or cleansed with 
gauze or cotton ; they should be let alone. Even the untreated cases termi- 
nate in spontaneous recovery. To hasten the cure it has been recommended 
that the ulcers be lightly touched with a 1 per cent. . solution of nitrate of 
silver once a day. 

PERLECHE 

Perleche is an ulcerative process, probably nonspecific in character, 
which confines itself to the angles of the mouth. It occurs throughout 
childhood, but is perhaps most common about the second or third year of 
life. It is commonly seen in children suffering from glandular tuberculosis 
and other forms of general malnutrition. Lack of cleanliness in the care 
of food utensils and unhygienic surroundings predispose to this infection. 
It may be transferred to other members of the family by direct contact, as 
in kissing, or by indirect means, such as the use of common food utensils 
and toilet articles without proper sterilization. One corner of the mouth 
is nearly always infected from the other by the tongue transferring the con- 
tagion. This accounts for the bilateral character of this disease. 

Symptomatology. — The corners of the mouth are the sites of ulcers 
which first make their appearance in the form of slight fissures; later the 
ulceration extends and is covered by a sticky exudate and the surrounding 
parts are swollen and indurated. Pain and slight bleeding are produced 
by stretching the corners of the mouth and forcible removal of the scab 
leaves a raw and bleeding surface. From these ulcers there radiate from 
the corners of the mouth well-marked fissures, giving to this condition a 
characteristic appearance, which cannot be mistaken for any other form 



GEOGBAPHICAL TONGUE 155 

of ulceration except the syphilitic ulcer which occurs at this point. The 
differentiation between these two conditions, however, may be made by the 
existence or absence of other syphilitic symptoms. 

Treatment. — In the great majority of cases even the untreated cases 
terminate in spontaneous recovery ; in a few instances, however, the disease 
may continue for months. The scabs covering the ulcers should be softened 
by the application of a 1 per cent, boracic acid ointment; after a number 
of days they may be removed without producing much irritation. The 
surfaces thus exposed should be painted two or three times a day with a 
2 per cent, nitrate of silver solution. Following the application of the 
silver the ulcers should be washed and some such sedative ointment as the 
following should be applied: Bismuth subnitrate, 5i, acid salicyl., grs. xx, 
lanolin, q. s. ad §i. 

ELONGATED UVULA 

An elongated uvula may, by irritating the base of the tongue and the 
pharynx, produce a most persistent and irritating cough, which may be 
greatly aggravated when the child is lying down. As a result of constant 
coughing the child loses sleep and becomes more or less nervous and hys- 
terical, and this nervousness in turn may increase the paroxysms of cough- 
ing. When this symptom group occurs in children having a normal tem- 
perature and with no physical signs in the throat or lungs to account for it 
the uvula should be inspected, and if it be found elongated to such an 
extent that it can readily come in contact with the pharynx and tongue, it 
should be amputated. Clipping off the uvula is a simple operation which 
effectually terminates the existing attack and prevents recurrences. 

Astringent gargles or astringents applied in other ways to the uvula 
are effective in relieving the attack. A twenty per cent, solution of alum or 
5 to 10 per cent, solution of tannic acid, when applied to the uvula, 
usually causes it to contract and relieves the irritating cough. A good- 
sized dose of bromid of potash should be given at the same time. 

GEOGRAPHICAL TONGUE 

{Ringworm of the Tongue; Desquamative Glossitis; Wandering Rash of 

the Tongue) 

Symptomatology. — One or the other of these names is used to describe 
a condition of the tongue which has little or no pathological significance, 
but the very remarkable change which it produces in the surface of the 
tongue always attracts attention and calls for explanation. There appears 
usually on the dorsum a grayish-white patch distinctly outlined by the sur- 
rounding pink mucous membrane; as this increases in size it takes on a 
characteristic appearance; in the center it becomes more or less denuded 
of the superficial epithelial layers, which gives it a reddish color. As these 
red patches increase in number they may coalesce and give to the tongue a 
geographical appearance. If the scrapings from these elevated borders be 



156 DISEASES OF THE MOUTH AND ESOPHAGUS 

placed under the microscope, in addition to the epithelium and detritus thus 
obtained there will be found cocci, sarcinse and other microorganisms, none 
of which have as yet been definitely associated with the etiology of this con- 
dition. It occurs most commonly from the first to the fifth year of life, 
but it may be seen at any time during infancy and childhood. 

Treatment. — This condition is of no diagnostic or pathologic impor- 
tance. It may occur in perfectly normal children and its presence furnishes 
no clue to the existence of any constitutional or local disorder. It requires 
no treatment, although painting the tongue with 5 or 10 per cent, solu- 
tions of nitrate of silver and afterward thoroughly irrigating the mouth 
with a mild alkaline antiseptic have been recommended. This condition 
may persist for months or years and then disappear, or it may continue 
throughout life. 

TONGUE-TIE 

A short frenum which binds the tongue to the floor of the mouth is 
the cause of this deformity. It interferes with sucking and articulation and 
prevents the protrusion of the tongue beyond the gums. 

The diagnosis of tongue-tie in backward children is frequently made, 
when it does not exist, to account for their defects in articulation. The 
treatment consists in cutting the frenum and separating the tissues far 
enough back to liberate the tongue. 

HARE-LIP 

In the formation of the upper lip a central process unites with two 
lateral processes just beneath the nostrils. When this union fails to occur 
the lip remains fissured or slit on one or both sides, producing a single or 
double hare-lip. The deformity may vary from a slight indentation to a 
fissure completely separating the lip and extending into the nostril. When 
this deformity occurs on both sides it is much more difficult to overcome 
by surgical interference. 

Hare-lip greatly interferes with the feeding of the infant and sometimes 
makes nursing impossible. It is important in all cases to encourage nursing 
and supplement the feeding by pumping out the mother's milk and feeding 
it with a dropper. As soon as the nutritional processes of the body have 
been well started a surgical operation for the relief of this condition is 
advisable. This may usually be done about the fourth week of life. 

CLEFT-PALATE 

Cleft-palate is commonly associated with hare-lip and not infrequently 
with other congenital deformities. Heredity is the most common etiological 
factor; not infrequently more than one case occurs in the same family. 
This deformity is said to occur more commonly in boys; I observed, how- 
ever, one family in which there were four girls all born with cleft-palates 
and hare-lips, and three boys entirely free from these deformities. The 



PERIESOPHAGEAL ABSCESS 157 

fissures may involve only the soft palate or both the hard and soft palate. 
It results from failure of the palatal arches to unite. Cleft-palate, especially 
when associated with hare-lip, is a serious deformity and not infrequently 
interferes to such an extent with the taking of food that the infant dies 
from marasmus. This deformity makes it difficult to keep the infant's 
mouth clean and thereby predisposes to thrush. 

The early treatment of these cases consists in devising ways and means 
by which the infant may be fed with breast milk. By pumping the breasts 
of a wet nurse milk may be secured, which may be fed to the baby by a 
spoon or dropper. The greatest care should be exercised to keep the in- 
fant's mouth clean by gently washing it with warm water. If the operation 
for hare-lip is successfully made during the second month, there will be 
less difficulty in feeding and the operation for cleft-palate may be deferred 
until the end of the second year. As the treatment, however, is essentially 
surgical, both the time and the nature of the operation may be left to the 
judgment of the surgeon. 

ESOPHAGITIS 

Esophagitis is an inflammation of the esophagus commonly due to the 
swallowing of caustic alkalies or mineral acids or to the extension of some 
inflammation from the pharynx. 

Symptomatology. —In caustic esophagitis the stomach is usually in- 
volved; there are great pain, restlessness, crying, and difficulty in swallow- 
ing; any attempt at taking food or water aggravates these symptoms. 
Nausea and vomiting are common and the vomited matter may contain 
blood. An examination of the mouth and throat shows that these mucous 
membranes are swollen and inflamed. The severity of the symptom group 
depends upon the quantity and concentration of the caustic fluid swal- 
lowed. In severe cases the injury to the stomach may cause a rapidly fatal 
termination. In the milder cases of esophagitis the above symptom group 
is less severe and may gradually subside; convalescence resulting either in 
complete recovery or in stricture of the esophagus. 

Treatment. — This consists in relieving the pain when necessary by hypo- 
dermic injections of morphin and in the giving of nutrient and saline 
enemata until the child is able to swallow milk and water. Later surgical 
intervention may be necessary to relieve the esophageal stricture. 



PERIESOPHAGEAL ABSCESS 

Periesophageal abscess is usually due to suppuration of lymph nodes, 
disease of the spine or to foreign bodies; tuberculosis is the most common 
cause. 

The symptoms depend largely upon the location of the abscess and are 
usually those of esophageal stenosis. When located high up, the trachea, 
larynx and recurrent laryngeal nerve may be involved. In these cases 



158 DISEASES OF THE STOMACH 

there may be dyspnea, aphonia and violent attacks of coughing. The ab- 
scess may cause death by opening into the esophagus or trachea. 

The prognosis is bad; spontaneous rupture may rarely result in re- 
covery. Surgical intervention is advisable in selected cases. 

BRANCHIAL CYSTS 

Branchial cysts are cystic tumors having their origin in the faulty 
closure of the branchial clefts of fetal life. They are usually located in 
the anterior-lateral surfaces of the neck in close proximity with the great 
vessels. This rare form of cystic tumor yields readily to radical surgical 
treatment. 

CONGENITAL MALFORMATIONS OF THE ESOPHAGUS 

Griffith notes the following forms of congenital malformations of the 
esophagus: "1. Total absence of the esophagus. 2. Partial or complete 
doubling of esophagus. 3. Tracheoesophageal fistula without other lesion 
of the esophagus. 4. Congenital stenosis. 5. Congenital dilatation. 6. Ob- 
literation of the esophagus in only a portion of its extent unaccompanied 
by fistula. 7. Obliteration of a portion of the esophagus with tracheo- 
esophageal (or bronchoesophageal) fistula. 

"Treatment. — This is entirely discouraging. Cases of stenosis have re- 
covered, but all instances of complete obstruction have died. The weak- 
ness of the child and its early age make operative interference a question- 
able procedure; yet gastrostomy offers the only hope. This operation was 
first done in the case of Steel, and has been performed since then in those 
of Hoffmann, Hoppich, Villemin, Kirmisson, and Dickie. The child 
should be kept on its side to allow the mucus to flow from the mouth. It 
may be fed through the gastric fistula. Should it recover an effort may 
later be made to repair the esophagus by a lateral operation in the neck. 
This indeed was attempted unsuccessfully in Hoffmann's case as a primary 
operation and gastrostomy resorted to later/' 



CHAPTEE XVIII 
DISEASES OF THE STOMACH 

ACUTE GASTRIC INDIGESTION 

Etiology. — The causes of this condition, especially in the infant, may 
be grouped under two headings : first, Physiological Gastric Incompetency ; 
second, Improper Food. 

Physiological Gastric Incompetency. — Physiological gastric incom- 
petency may be inherited or acquired ; it is most pronounced during the hot 
summer months. In feeble, malnourished, neurotic infants there may be 



ACUTE GASTEIC INDIGESTION 159 

such a predisposition to acute gastric indigestion that slight causes, such 
as rapid eating, coddling and exercise directly after meals, slight changes 
in the food formula, dentition, nervous excitement, or the swallowing of 
mucus in catarrhal conditions of the respiratory passages, may cause this 
trouble. It is important therefore in every case of acute gastric indigestion 
to consider not only the apparent exciting causes, but also the probable in- 
fluence which the physiological gastric incompetency of the individual in- 
fant may play in the production of this symptom group. 

Improper Food. — The most common exciting causes are to be found 
either in the quantity or in the quality of the food. It may occur in breast- 
fed babies from irregularities in nursing; that is to say, giving too much 
food at too short intervals. The breast milk itself, however, may cause in- 
digestion by changes in its composition produced by nervous excitement on 
the part of the wet nurse, or by the character of her food, or by the un- 
hygienic life she may be leading. Artificial food unsuited to the digestive 
capacity of the child, or properly prepared food given in too great quantities 
or at too short intervals, are the most common causes of acute gastric in- 
digestion. Eapidly increasing the strength of the food formula, especially 
in fat and protein, or changing from one of the proprietary foods to a 
modified milk formula are common exciting causes. In older children the 
taking of improper food, or food beyond the digestive capacity of the child 
may produce very severe attacks of gastric indigestion. Candy, pastry, 
fruit, berries and vegetables given to infants and children whose age and 
digestive capacity wholly unfit them for the taking of these foods are com- 
mon causes of gastric indigestion. 

Symptomatology. — The attack is usually ushered in with colic, nausea, 
irritability, fretfulness, restlessness and a slight elevation of temperature. 
The appetite is lost, the tongue is coated and after a time vomiting occurs, 
the vomitus containing undigested food that has been perhaps retained in 
the stomach for many hours. The irritability of the stomach and vomiting 
may recur at intervals for a number of hours, and the taking of food may 
prolong and aggravate these symptoms. Following the vomiting the pain, 
fever and nervous symptoms gradually subside. During the next few days 
the stomach is irritable and vomiting is easily provoked, and more or less 
intestinal irritation with diarrhea is present. In young, delicate and mal- 
nourished infants all of these symptoms may be greatly exaggerated. The 
fever may run as high as 104° or 105° F. and great prostration, extreme 
pallor, great nervous irritability and even convulsions may occur. But in 
these severe cases, as in the milder ones, the emptying of the stomach by 
vomiting and the unloading of the intestinal canal by a cathartic quickly 
cause a subsidence of all the acute symptoms, leaving the child weak, and 
suffering from a gastric irritability from which it slowly convalesces under 
careful treatment. In older children the fever is. as a rule, absent and the 
nervous symptoms are much less marked, but gastric colic or severe gas- 
tralgia is a much more common symptom than it is in the infant. 

Prognosis. — The prognosis is good and there is rarely any danger from 
12 



160 DISEASES OF THE STOMACH 

gastric indigestion except in young and very delicate infants, and then the 
danger is commonly due to convulsions. If the stomach is emptied and 
food is stopped the infant should be convalescent within three or four days. 

Treatment. — If vomiting has not occurred, and even if it has and there 
is reason to believe that the stomach has not fully emptied itself, it is ad- 
visable to wash out the stomach with a lukewarm physiological salt solu- 
tion; this procedure often arrests the nausea and vomiting. Small doses 
of calomel should be given, a tenth of a grain every half hour until one 
grain is taken, and all food should be stopped and only sufficient water 
given to administer the calomel. Kest for the stomach and quiet for the 
infant during the next few hours are necessary. After three or four hours 
a dose of milk of magnesia should be given to assist the calomel in its 
action. Castor oil, which is likely to prolong the gastric irritability, should 
be abstained from. Commonly no other medication is needed in these 
cases, but if the gastric irritation is prolonged, a teaspoonful of simple 
chalk mixture or lime water may be given every two or three hours, or 
sodium bicarbonate or compound chalk powder in 2-grain doses may be 
given in a little water every two hours. After some hours, when the infant 
demands food, it may be given water to drink and later barley water ; if the 
infant be very young the barley water may be malted. Barley water, beef 
broth, beef juice and whiskey and water should constitute the nourishment 
for twenty-four or thirty-six hours, and then small quantities of fat-free 
cow's milk should be added to the barley water, and as the child convalesces 
it may gradually return to its original diet. In breast-fed babies the breast 
milk may be carefully resumed after the stomach has been rested for twelve 
or twenty-four hours. 

In older children the treatment is somewhat different; the gastric pain 
must be relieved by hot applications to the stomach, spirits of chloroform 
and whiskey internally, and if the child has not vomited an emetic may be 
given, preferably the syrup of ipecac. Later, as the nausea, vomiting and 
pain subside, a saline cathartic should be given, the stomach should be rested 
and the child dieted according to its age and physical condition. The fol- 
lowing prescription is of value during this period : 

J$ Acidi hydrochlorici dil 3 i 

Pepsin puri grs. XV 

Glycerini 3 ii 

Aquae destillatse ad § ii 

Sig. Teaspoonful after eating for a child six years of age. 

ACUTE GASTRITIS 

Etiology and Pathology. — Noncorrosive Form. — Acute gastritis is 
very commonly a sequel of acute gastric indigestion. In feeble, malnour- 
ished, neurotic children this sequence is most commonly noted. The pro- 
longed heat of summer may, by reducing the vitality of the infant, pre- 
dispose it to attacks of gastritis. Spoiled food, especially milk which has 
undergone bacterial contamination, is a potent factor. Gastritis is also 



ACUTE GASTRITIS 161 

a common complication of the acute infections, especially influenza, measles 
and whooping-cough. Acute enteritis, whatever may be its causes, is very 
commonly complicated with acute gastritis, and an acute gastritis which 
does not yield promptly to treatment is almost always followed by more or 
less enteritis. 

In the ordinary form of acute gastritis the stomach is found to con- 
tain a thick, tenacious mucus, closely adherent to the mucous membrane, 
and this mucus may be mixed with a dark granular substance which analy- 
sis proves to be blood. The mucous membrane presents the appearance of 
an acute catarrhal inflammation. It is hyperemic, swollen, thickened, is 
infiltrated with round cells, shows a superficial loss of epithelium and may 
be dotted with petechial hemorrhages. Small ulcers, similar to those which 
occur in gastroenteritis, may be present in the more severe cases ; a pseudo- 
membrane rarely occurs. 

Corrosive Gastritis. — Corrosive gastritis differs radically in its etiol- 
ogy and clinical history from ordinary gastritis. This severe form of in- 
flammation of the stomach may be excited by such caustic poisons as am- 
monia, carbolic acid, mineral acids, arsenic and other corrosive poisons. 
In this condition the mucous membrane is ulcerated, and the extent of these 
ulcerations will depend upon the severity of the caustic action; they may 
even cause perforation. In milder cases, where the caustic poison is not so 
concentrated or where the poison is taken into a full stomach which is 
quickly emptied by vomiting, the ulcerations may not be so extensive and 
the patient may recover. Eecovery may be followed by a cicatricial con- 
traction of the stomach, the pharynx or the esophagus, producing deformi- 
ties with more or less stenosis of the esophagus or pylorus. A severe 
esophagitis and more or less pharyngitis are commonly present. 

Symptomatology. — In ordinary cases, not corrosive, the beginning of 
the attack cannot be distinguished from an acute gastric indigestion, except 
perhaps in the severity of the symptoms. Nausea, vomiting, pain, fever and 
prostration mark the onset of the disease. The vomiting, which is an early 
symptom, is very severe; the stomach is emptied of its contents, but the 
nausea and vomiting continue, resulting in the expelling of small quanti- 
ties of sour mucus or bilious matter which may be tinged with blood; the 
vomitus unlike that found in Recurrent Vomiting never contains free 
hydrochloric acid. The taking of food and water greatly aggravates these 
symptoms. Pain in the stomach is commonly present in older children, 
and after a few hours is followed by epigastric tenderness. The fever is 
especially high in infants and may within the first few hours reach 104° 
or 105° F., but after the stomach has emptied itself it gradually subsides. 
Convulsions may occur in young infants and is a dangerous complication 
in weaklings. Prostration is great, especially early in the disease, but grad- 
ually subsides under proper treatment. The tongue is coated, the breath 
is foul, and on the second or third day there is usually a complicating diar- 
rhea. In favorable cases where treatment is begun early, convalescence 
should be established between the third and the sixth day. But in cases 



162 DISEASES OF THE STOMACH 

that are badly managed and improperly fed before convalescence is estab- 
lished, relapses occur, and the disease may in this way be. prolonged or con- 
verted into a gastroenteritis. The above clinical picture applies to infants. 
In older children the fever, vomiting and prostration are much less severe 
and convulsions rarely occur, but the gastric colic is commonly more marked. 

In the corrosive form of this disease, that produced by caustic poisons, 
all of the above symptoms are greatly exaggerated. The pain is intense, 
the vomited matter commonly contains blood, and prostration is extreme; 
these symptoms may continue for a number of days, resulting in death. 
In milder cases there is a prolonged convalescence covering weeks and 
sometimes months, resulting in the deformities and contractures above 
mentioned. In this form of the disease there is also great pain in swallow- 
ing due to the complicating pharyngitis and esophagitis. 

Treatment. — The early treatment of the noncorrosive form of acute 
gastritis is the same as that of acute gastric indigestion. The stomach 
may be emptied by lavage if the vomiting has not accomplished this pur- 
pose. An enema should be given and absolute quiet for the patient and rest 
for the stomach insisted upon. Older infants and children may get more 
or less comfort and satisfaction in being allowed to suck small pieces of ice 
held in a cloth, but no food or medication is indicated for some hours after 
the onset of the attack. After vomiting, however, has subsided, a dose of 
milk of magnesia may be given, and, if necessary, water or barley water may 
be given in small quantities. On the second day of the disease the diet 
should consist of barley water, meat juice and small quantities of Nestle's 
food to which a diastase has been added. On the third day, in addition to 
the above-named foods, whey may be given. On the fourth day, if the 
child's convalescence has been satisfactory, a small quantity of skimmed 
milk may be added to the whey or Nestle' s food and from this time the 
return to cow's milk should be very gradual. If the infant happens to be 
breast-fed it may return to the breast milk on the third day. In very 
young and delicate bottle-fed infants it may be advisable to hasten con- 
valescence by obtaining a wet nurse on the third or fourth day of the 
disease. Throughout the attack the bowels must be kept open ; this may 
be accomplished by calomel, milk of magnesia and enemata. It is ad- 
visable in all conditions where the stomach is inflamed to especially avoid 
fats or oils either in the form of food or medicines. For this reason castor 
oil is not advisable as a cathartic, and cream is not to be recommended as 
a food until convalescence is well established. 

Other medication than that above mentioned is rarely necessary in 
cases of simple gastritis in infants, but if the vomiting and gastric irrita- 
tion persist half-teaspoonful doses of simple chalk mixture may be given 
at intervals of one or two hours, or compound chalk powder in 2 or 3-grain 
doses may be used. In older children it may be necessary to make hot ap- 
plications to the stomach for the relief of pain and, after the stomach has 
been thoroughly emptied, to give small doses of bismuth and sometimes 
paregoric, put up in chalk mixture, for the relief of the pain and gastric 



DILATATION OF THE STOMACH 163 

irritation, but the bismuth and paregoric should be dispensed with as soon 
as the special indications for their use have disappeared. 

In corrosive gastritis it is absolutely necessary to empty the stomach 
as soon as possible with some kind of an emetic, such as the syrup of ipecac. 
After this has been accomplished, hot applications should be made to the 
stomach and morphin should be given hypodermically for the relief of pain. 
A solution of muriate of cocaine in 1/30-gr. doses may be given every 
hour for three or four hours. Following this the pain and irritation of the 
stomach may be relieved by chalk mixture containing small doses of pare- 
goric or morphin, and the child must be kept alive by hypodermoclysis of 
physiological salt solution and by the administration through the bowel of 
physiological salt solution, whiskey and nutrient enemata. The stomach 
is to have as long a period of rest as possible. In some instances it may 
be necessary to abstain from food of all kinds for four or five days, allow- 
ing the child on the second or third day small quantities of water. When 
the gastric ulceration permits the administration of food the dietetic man- 
agement of the case is the same as that just given in acute gastritis, except 
that one must progress more slowly with the feeding and that milk may 
have to be abstained from for a period of four or five weeks. 

DILATATION OF THE STOMACH 

Etiology. —In infancy the walls of the stomach are thin and the muscu- 
lar resistance slight. These anatomical peculiarities predispose to dilatation. 
Eickets, chronic gastritis, syphilis, anemia and general malnutrition still 
further weaken the walls of the stomach, which makes it possible for slight 
causes to produce distention and permanent dilatation. The most com- 
mon exciting cause is the giving of food in large quantities at short in- 
tervals. If an infant four months of age is fed six or eight ounces of food, 
or all it will take, when on account of its malnutrition it should be fed only 
three or four ounces at intervals of three or four hours, it is evident that 
gastric distention and permanent dilatation may result. Chronic gastric 
indigestion and chronic gastric catarrh are also common causes of dilatation. 

Symptomatology. — In the beginning, vomiting, gastric pain, tenderness 
and the other symptoms of chronic gastric indigestion are present, and 
general malnutrition, great emaciation, marked anemia and profound 
asthenia gradually develop. 

Diagnosis. — The diagnosis, however, is made by the physical examina- 
tion. The abdomen is distended and tympanitic, especially in the epigastric 
region. The quantity of food which the infant takes may indicate dilata- 
tion. When the stomach is full its lower outline may be mapped out by 
percussion if the infant is held in an upright position ; if this dull outline 
reaches nearly to the umbilicus the stomach is dilated, if it reaches below 
the umbilicus, it is, according to Holt, much dilated. After the stomach 
has been washed out it may be inflated by pumping air into it with a 
stomach tube; in this way the distended stomach may be outlined against 



164 DISEASES OF THE STOMACH 

the thin abdominal wall and the limits of its tympanitic note be marked 
out by percussion. By some one of the above methods one can, as a rule, 
determine whether or not the stomach is dilated, but the outlining of the 
infantile stomach is after all more difficult in practice than it is in theory. 

Prognosis. — The above description applies only to simple dilatation pro- 
duced by the etiological factors given above and does not apply to the forms 
of dilatation which occur from organic stricture of the pylorus. The prog- 
nosis, therefore, depends largely upon the severity of the underlying predis- 
posing causes; if these are present in a marked degree it is very much 
more unfavorable. If, however, the constitutional disorders are not such 
as to produce a profound malnutrition then the prognosis under proper 
treatment is comparatively good. 

Treatment. — The treatment is largely dietetic and is practically the 
same as that given for chronic gastritis. The food should be carefully se- 
lected to suit the individual infant ; breast milk, whey and, where the child 
is altogether bottle-fed, small quantities of fat-free milk combined with a 
malted cereal mixture may be recommended. Great care as to diet, over a 
long period of time, is necessary to obtain success in these cases, and it is 
especially advisable that the food should be given at rather longer intervals 
and in rather smaller quantities than the weight and age of the baby would 
justify under normal conditions. Most important also is the hygienic man- 
agement ; the infant should have as much fresh air and sunlight as possible, 
and, if the climatic conditions are unfavorable, it should be removed to a 
climate where an out-of-door life is possible. 

In the medical treatment hydrochloric acid and nux vomica, combined 
with essence of pepsin, in doses suited to the age of the infant or child, are 
of value. It may also be necessary to wash out the stomach at intervals 
and to give as a laxative occasional doses of calomel or milk of magnesia. 
If rickets, syphilis or tuberculosis be present they should receive proper 
treatment. 

ULCER OF THE STOMACH 

This is very rare in childhood and even more so in infancy. The diag- 
nosis is most frequently made on the post-mortem table, the child having 
died from some intercurrent disease. From these autopsy findings it is 
evident that the disease is not commonly characterized by a symptomatology 
sufficiently definite to make the diagnosis plain. When these ulcers occur, 
as they sometimes do in connection with acute gastritis, we may have marked 
gastric irritation with nausea and vomiting; when there is a bloody vomitus, 
associated with tarry stools, the diagnosis is commonly simple enough. 
Rotch and others have recorded cases of simple perforating ulcers, but these 
cases are extremely rare. Tuberculous gastric ulcers are also seldom seen. 

Treatment. — In severe cases rectal feeding may be necessary and opium 
may be required for the relief of pain, but for the most part the treatment 
consists in a preliminary rest for the stomach, followed by a carefully 
regulated diet, such as is necessary in acute gastritis. The use of alkalies, 



ACUTE GASTRODUODENITIS 165 

such as lime water and sodium bicarbonate, and stomach sedatives, such as 
bismuth, are of value in relieving the symptoms. If perforation occurs 
laparotomy is to be resorted to at once. 

ACUTE GASTRODUODENITIS 

(Catarrhal Jaundice) 

Catarrhal jaundice occurs usually between the second and the fifth year, 
being almost unknown in infancy and uncommon after the fifth year. It 
is probable that all cases are due to some infection, which produces more 
or less duodenal catarrh with an accompanying catarrh of the common bile 
duct, resulting in its obstruction. The bacteriology of this condition is not 
known, and at the present time it seems improbable that all cases are due 
to the same bacterial infection. It is much more probable that the disease 
may be produced by a number of infections, prominent among which is in- 
fluenza. The writer on a number of occasions has seen two cases in the 
same family of children, where there was a house epidemic of influenza. 

Symptomatology.' — The early symptoms are those of mild gastric indi- 
gestion, nausea, vomiting, gastric discomfort, fever from 100° to 103° F., 
more or less headache, irritability, nervousness, mental depression and gen- 
eral discomfort. These symptoms continue for three or four days and then 
jaundice appears and the diagnosis is made. The skin and conjunctiva 
assume a yellowish hue which gradually deepens to a saffron tint. The 
child is usually constipated, the stools are white or clay colored and have 
a bad odor. The urine contains bile and is of a yellowish-brown color. 
There are pain and tenderness over the duodenum, the tongue is heavily 
coated, there is much thirst and little appetite, and occasionally there is 
an uncomfortable itching of the skin, but this latter symptom is not so 
common as in the forms of chronic jaundice seen in the adult. The liver 
is almost always enlarged and remains so for some days after the jaundice 
has disappeared. The spleen may be palpated in most cases. 

Course. — The disease lasts from two to three weeks, and the symptoms 
are so uniform and the course so definite that it gives one the impression 
of a self-limited acute infection. In the ordinary course of the disease the 
gastric symptoms subside within the first week, the temperature becomes 
normal, the appetite returns, and the general discomfort disappears, but the 
jaundice, with the clay-colored stools and bile-colored urine, continues to 
the end of the third -week, when convalescence is usually established, but 
it may be delayed by errors in diet. 

Diagnosis.- — In early infancy catarrhal jaundice does not occur. The 
differential diagnosis from other conditions producing a sallow skin is made 
by the yellowness of the conjunctiva and by the bile in the urine. 

Treatment. — Preliminary to the onset of the jaundice, before the diag- 
nosis is made, the child is treated for ordinary gastric indigestion. With 
the onset of the jaundice calomel is to be given, followed by Rochelle salts, 
and throughout the course of the disease the bowels are to be irrigated every 



166 



DISEASES OF THE STOMACH 



day or every second day, and phosphate of soda is to he given in sufficient 
quantities to insure slight laxative action. The diet during the acute stages 
of the disease should be of skimmed milk, buttermilk, bread, cereals, broth 
and a little orange juice. Fats are to be especially avoided and meats are 
to be given sparingly, since the bile, as the author 1 many years ago dem- 
onstrated, is necessary for the ready digestion and assimilation of both fat 
and protein. The cereals are very well borne, especially if a diastase be 
given with the meals. 

CONGENITAL HYPERTROPHY OF THE PYLORUS 

This condition has attracted considerable attention in recent years, and 
there can be no doubt but that the clinical syndrome embraced under this 
heading is not so infrequent as formerly supposed, but there is still much 
difference of opinion as to the actual lesions which produce it. 

Etiology and Pathology. — It is generally conceded that there is a con- 
genital condition in which the pylorus is thickened and its lumen so greatly 









f 






A 








c . 


'fjf 
J 


- 







Fig. 25. — Congenital Stenosis op the Pylorus. (Bevan.) 

reduced, that it acts as a serious obstruction to the transfer of the food con- 
tents of the stomach to the small intestine. The pylorus may form a small 
tumor which can be felt and occasionally seen through the abdominal wall. 
The lumen at the point of greatest hypertrophy of the sphincter may be 
so small as to admit only a fine probe. It is also conceded that this mus- 
cular hypertrophy, which involves the pyloric end of the stomach as well 
as the pylorus itself, is associated with spasm, which greatly aggravates the 
constriction. Thompson suggested that the pyloric spasm might be the 
initial lesion occurring soon after birth, being produced by the swallowing 
of liquor amnii, and that this fluid and other irritating substances produced 
by the fermentation of food and mucus might continue the exaggerated 
1 Journal of Physiology, 1891. 



CONGENITAL HYPEKTKOPHY OF THE PYLORUS 167 



action of the pyloric sphincter and muscular coats of the stomach, and thus 
produce a secondary hypertrophy of these muscles, which would increase 
the constriction and finally result in 
more or less marked hypertrophy and 
permanent constriction. Whatever 
may be the relative importance of the 
congenital hypertrophy and the py- 
loric spasm in the etiology of this 
condition, it is conceded that both 
these factors exist, and I am inclined 
to believe with Koplik that there are 
two distinct groups of cases: one in 
which there is a spasm of the pylorus 
and pyloric end of the stomach, with 
little or no hypertrophy, and the 
other in which the essential lesion is 
hypertrophy of the pylorus, and that 
the symptom group in these cases is 
aggravated by an associated pyloric 
spasm. 

Symptomatology. —The first and 
all-important symptom in these cases 
is vomiting. In the great majority 
of cases it begins in the third or 
fourth week, but in rare instances it 
may begin a few days after birth or 
may be delayed to the seventh or the 
eighth week. In the beginning the 
vomiting may occur only once or 
twice in the twenty-four hours, but gradually increases in frequency and 
force, until, within the course of a week or ten days, nearly all of 
the food is vomited directly after taking. In the rapid development 
of this symptom there can be little doubt but that pyloric spasm 
plays an important role, and even during the height of the disease 
there is at times a strange intermittency in the force and frequency of the 
vomiting. Instead of occurring with great force directly after the taking 
of food this character of vomiting may be superseded for a few hours by 
comparative tolerance on the part of the stomach for food, and the vomiting 
may occur only after the food has remained in the stomach for hours, and 
again, directly after vomiting, food may be taken and retained until after the 
next feeding, when the whole contents of the stomach are ejected with con- 
siderable force. The infant ceases to gain in weight and then commences 
to lose and, as the chronic vomiting continues, becomes emaciated and 
malnourished to the last degree. Constipation is always present; it may 
exist with a discharge from the bowel several times during the day of small 
liquid stools, consisting largely of mucus and bile. A close study of these 




Fig. 26. 



-Congenital Stenosis of 
Pylorus. 



Longitudinal section, through tumor mass. 
(Bevan.) 



168 DISEASES OF THE STOMACH 

discharges will show that comparatively little or no food has passed from 
the stomach into the intestine. After taking food the child suffers more or 
less gastric discomfort, and if the disease continues for a long time, there is 
more or less marked dilatation of the stomach. It is an afebrile condition. 

All of the above symptoms may be produced by pyloric spasm even 
though there be little or no hypertrophy of the pylorus, but when marked 
hypertrophy of the pylorus exists the above symptom group is exaggerated, 
and there are in addition two physical signs of great diagnostic importance. 
One of these, the most characteristic of all, is a small, movable nodule 
which may be felt on deep pressure in the region of the pylorus, between 
the margin of the liver and the umbilicus. This tumor, which should al- 
ways be searched for, is the pathognomonic sign of hypertrophy of the 
pylorus, and in cases where it cannot be felt there must remain some doubt 
as to the presence of this condition. The other sign which is commonly 
noted in these cases is the peristaltic movements of the stomach, which can 
be seen through the distended abdominal wall. Valuable information as to 
the patulency of the pylorus may be obtained by giving the infant a large 
dose of subnitrate of bismuth, and one hour later determining by an X-ray 
picture whether or not the bismuth has passed the pylorus. 

Diagnosis. — According to Koplik, the diagnosis of pyloric spasm without 
hypertrophy of the pylorus is made largely by the absence of the pyloric 
tumor, and the presence of the stomach peristalsis and a projectile vomiting 
which empties the stomach, and the presence in the stools of a certain 
amount of fecal matter, which indicates that considerable food may have 
passed from the stomach into the intestine. The diagnosis of hypertrophy 
is made by the presence of all the symptoms of pyloric spasm, plus the 
pyloric tumor, the stomach peristalsis, the almost complete absence of fecal 
matter in the stools and retentive vomiting in contradistinction to full 
vomiting. Morse says, the most important points in favor of spasm in 
doubtful cases are the absence of a palpable tumor, or, if a tumor is present, 
its cord-like feel, the presence of intermittent contraction and relaxation 
of the tumor, and rapid improvement under medical treatment and regula- 
tion of the diet. He believes that a cord-like tumor may sometimes be felt 
when no hypertrophic stenosis exists, and that in some cases of hypertrophic 
stenosis no tumor can be felt. He also says that if the baby is breast-fed the 
chances are greatly in favor of hypertrophic stenosis, and if it be artificially 
fed, the chances are even. 

The only common disease with which hypertrophy of the pylorus may be 
confused is chronic gastric catarrh. This condition may be differentiated 
by the fact that in chronic gastric catarrh there is apparent cause for the 
onset of the vomiting and also for its continuation, and the vomiting in 
this condition subsides when the stomach is rested and a proper diet is 
given, so that there is little reason for mistakes in diagnosis after the con- 
ditions have been studied for a few days. 

There are other very rare conditions, such as stricture of the duodenum, 
either congenital or resulting from cicatricial contractions following ulcers, 



CONGENITAL HYPERTROPHY OF THE PYLORUS 169 



and scars of the pylorus, which are so infrequent that they scarcely deserve 
consideration. In the event, however, of the existence of these conditions 
their treatment would he the same as that of congenital hypertrophy of the 
pylorus. 

Prognosis — The prognosis of pyloric spasm uncomplicated by hyper- 
trophic stenosis is 
favorable. But the 
prognosis of pyloric 
stenosis, which is al- 
ways complicated by 
pyloric spasm, is 
grave, since many of 
these cases are not 
relieved by dietetic 
treatment. The sur- 
gical treatment, how- 
ever, is successful in 
about 50 per cent, 
of these cases, and 
the after results are, 
as a rule, good, al- 
though Koplik notes 
that quite a percent- 
age of the cases 
which survive the 
operation ultimately 
develop grave forms 
of malnutrition. The 
fact remains, how- 
ever, that in a large 
percentage of these 
otherwise hopeless 
cases, surgery saves 
the life of the child 
and gives it a fair 
chance to be restored 
to a satisfactory con- 
dition of health. Of 
the five operative 
cases that have come within my personal knowledge, four recovered and are 
now apparently well. 

Treatment. — In view of the fact that a large percentage of these cases 
may be cured without resorting to the knife, it is advisable that every 
ease should have careful dietetic and medical treatment until it has been 
fully demonstrated that such treatment is of no avail. Since all of these 
cases occur so early in life, the great majority of them are developed on 




Fig. 27. — Pylokic Stenosis. (Radiograph.) 
Taken three-quarters of an hour after the administration of 
bismuth paste. Note fine stream of paste escaping from 
the pylorus. Patient age thirteen weeks. Complete recovery 
without operation. (Max Dreyfoos.) 



170 DISEASES OF THE STOMACH 

breast feeding, but, whatever may be the food of the infant, with the onset 
of the symptoms the stomach should be washed out with a sodium chlorid 
solution (one level teaspoonful to a pint of water), and throughout the 
treatment, especially where retentive vomiting is present, stomach washing 
should be resorted to, from time to time, as necessary. After the preliminary 
washing of the stomach no food should be given for a period of at least 
twenty-four hours, but during the latter portion of this time small quanti- 
ties of salt solution may be given by the mouth. If this is retained two or 
three small breast feedings may be given within the next twenty-four hours. 
If the breast milk disagrees and the vomiting recurs, the stomach should 
have a rest and the breast milk of another wet nurse may then be tried. 
Skimmed breast milk will sometimes be retained when ordinary breast 
milk will not. It is important that the breast milk be given in small quanti- 
ties and at intervals of at least four hours during the first three or four 
days of the treatment; in some instances the gastric irritation and pyloric 
spasm may be relieved by giving directly before each nursing a few tea- 
spoonfuls of equal parts of water and lime water. During this period of 
insufficient nourishment small quantities of salt solution may be given by the 
mouth, and 5 or 6 ounces of the same solution may be thrown high up into 
the bowel at such intervals as may be necessary to overcome thirst and to 
supply the body with fluids. If breast feeding fails entirely a radical 
change in the food may be resorted to. Whey and peptonized fat-free milk 
are foods which may serve the temporary purpose of allaying gastric irrita- 
tion and pyloric spasm, and thus pave the way for a third trial of breast 
milk. If success follows any form of dietetic treatment one should be most 
careful not to change the diet of the infant until the condition of the child's 
stomach warrants, and the nutrition of the infant demands that a change 
should be made. In the event, however, that all dietetic measures fail, the 
patient should be prepared for operative treatment by hypodermoclysis of 
physiological salt solution and turned over to the surgeon for operation. 
He may then determine the nature of the operation to be performed in the 
individual case. Gastroenterostomy, pyloroplasty and Loreta's operation 
have all been performed with success in these cases ; the first of these is the 
favorite at the present time. 

CHRONIC GASTRITIS 

{Chronic Gastric Catarrh) 

This is a very common disorder, especially in infants and young chil- 
dren, and is usually associated with diarrhea and chronic intestinal indiges- 
tion ; this subject will be more fully treated under the latter heading. 

Etiology. — Chronic gastric catarrh is frequent during the first year of 
life and is usually caused by taking too much food at too short intervals; 
this applies especially to bottle-fed babies. If for example an infant three 
months of age, that should be taking 4 ounces of food every three hours, is 
given 6 or 7 ounces or "all it will take," especially at irregular intervals, 



CHKOXIC GASTBITIS 171 

trouble will surely follow. The overworked stomach, becomes distended, its 
motor power diminished, its mucous membrane diseased, the gastric secre- 
tions impaired, but appetite and thirst may still continue, so that the in- 
fant's stomach is never empty, and fermentation and gastric irritation re- 
sult; such is the common etiology of this disease in young infants. Bad 
hygiene, impure air, lack of sunlight, filthy surroundings and constitutional 
diseases, such as tuberculosis, syphilis and rickets, which produce malnutri- 
tion and anemia, are important predisposing causes. Eecurring attacks of 
acute gastritis may be a part of the early history of this disease. In older 
children also, the cause is too much food and improper food at irregular 
intervals. 

Pathology. — The stomach is dilated and the mucous membrane is cov- 
ered with a tough tenacious mucus. The changes are somewhat similar to 
those found in acute gastric catarrh, except that the swelling and congestion 
of the mucous membranes are not so marked, and petechial hemorrhages 
and marked injection of blood vessels do not exist. The mucous 
membrane is infiltrated with round cells, is thickened, and there are ero- 
sion and degeneration of the epithelial cells, especially in and around the 
gastric tubules. 

Symptomatology. — Vomiting is the characteristic symptom. It may oc- 
cur every day, or every other day, or at longer or shorter intervals, depend- 
ing upon the severity of the case and the character of the food administered. 
In older children vomiting occurs more frequently in the early morning 
than at any other time, but in infants it may occur at any time when the 
stomach is overfull. The vomited matter consists of undigested food and 
of glairy, tenacious mucus which is acid from the presence of the fermenta- 
tion acids, acetic, butyric and lactic ; hydrochloric acid is almost never pres- 
ent. In infants gastric indigestion and diarrhea are common ; children over 
two years of age are, as a rule, constipated. For a long time the appetite 
may remain good and is unfortunately much larger than the digestive ca- 
pacity. The child is nervous, irritable, sleeps badly, frets, whines and de- 
mands more or less constant attention. It may cry for food and take with 
avidity more than the normal quantity, and yet surfer from gastric pain and 
discomfort soon after. It fails to gain in weight and as the disease pro- 
gresses there are loss of weight, dry skin and anemia. The face becomes 
thin and old-looking, the belly large and tympanitic and the legs thin ; the 
appetite is gradually lost, and emaciation and malnutrition increase until 
death occurs from exhaustion. This extreme picture, however, is fortunately 
not very common except in young infants. In older infants and children 
all of the symptoms are much less severe, the vomiting is not so frequent 
and the disease yields much more readily to treatment, so that, as a rule, 
the severe symptoms leading to extreme emaciation and profound malnutri- 
tion are uncommon unless the intestinal canal be involved. 

Diagnosis. — The diagnosis is not difficult, the chronic vomiting, gastric 
discomfort, epigastric tenderness associated with malnutrition and anemia, 
occurring as an afebrile condition in an infant, cannot be mistaken for any 



172 DISEASES OF THE STOMACH 

other disease except congenital pyloric spasm. (See Congenital Hyper- 
trophy of the Pylorus.) 

Prognosis. — The prognosis largely depends upon the age of the child 
and the stage of the disease when proper treatment is instituted. If the 
diagnosis is made early the prognosis is good even in young infants, but 
otherwise at this age it is very doubtful. In children over three years of 
age it is good, but it may require months or years in a well-established case 
to completely overcome all evidences of the disease. 

Treatment. — One of the first indications is to cleanse the stomach and 
keep it as clean as possible. In infants under one year of age this may 
very readily be done by washing out the stomach once a day with a weak 
bicarbonate of soda or sodium chlorid solution, one-half drachm to the 
pint; this warm alkaline solution should be used about three hours after a 
feeding. In older children the stomach tube cannot so readily be used and 
in these cases the cleansing may be done by milk of magnesia, Rochelle 
salts or sodium phosphate, taken before meals once or twice a day in suffi- 
cient quantities to relieve constipation. If the children are old enough it is 
also advisable to have them sip hot water in which has been dissolved some 
bicarbonate of soda ; this should be done one hour before meals. The careful 
selection of a proper diet is very difficult in these cases, and yet upon it 
depends their successful treatment. On general principles one may say it 
is advisable at all ages to avoid fats and to give small quantities of food at 
long intervals, the object being to have the stomach empty itself before it is 
required to undertake the digestion of another meal. The diet must, of 
course, suit the age and digestive capacity of the individual infant. If the 
food happens to be breast milk, then something must be radically wrong 
with that particular breast milk, or it must have been fed as to interval and 
quantity most unwisely. In such instances it is advisable, if the symptoms 
do not yield readily, to change to another wet nurse, and if this procedure 
fails the infant should be put upon modified cow's milk. Infants that have 
been taking cow's milk or other foods when the gastric catarrh developed 
are to have their milk formulas carefully regulated with reference to their 
digestive capacity. The foods that usually agree with these infants, fat-free 
milk, peptonized milk and buttermilk, may be tried in the order named. 
The fat-free milk and the peptonized milk should be diluted with dextrin- 
ized gruels, and, as the infant improves, dextrinized gruels may be dimin- 
ished and the quantity of skimmed milk or peptonized milk in the mix- 
ture gradually increased. The buttermilk mixture may be prepared by 
adding to a pint of buttermilk a tablespoonful of wheat flour and two 
tablespoonfuls of cane sugar, and boiling thirty minutes. This mixture may 
be given every four hours to infants between the ages of six and ten months, 
and the quantity should be one ounce less than they are months old. This 
is an excellent food and agrees with many cases. Meat juice, in suitable 
quantities, diluted with a little water, may be added to the infant's diet 
after it has been demonstrated that any one of the above-named milk prep- 
arations is agreeing with it. One of the proprietary milk foods, such as 



ETIOLOGY 173 

Nestle's, is often of value in the treatment of these cases. If the Nestle's 
food is used, 5 or 10 drops of a liquid diastase should be added to each feed- 
ing and later small quantities of fat-free or peptonized milk are to be 
added, and as these foods are added the proportion of the Nestle' s food is 
diminished, so that in time one of the milk preparations gradually replaces 
the proprietary food. In older children, as they commence their convales- 
cence, meat, eggs, cereals, bread and later orange juice may be added. 

The hygienic treatment of these cases is very important; it may be 
necessary to send them to a cool climate during the hot summer months 
and to a warm climate during the cold and disagreeable months of winter. 
The object of these changes is to put the infant under such climatic con- 
ditions as will give it plenty of sunlight and fresh air without subjecting it 
to the depressing effects of the heat of summer or the chilling effects of 
damp, cold winters. If it be necessary to keep it out of doors in cool 
weather it must, because of its diminished vitality, be dressed warmly; 
above all, the feet and legs should be kept warm by hot water bottles and 
proper clothing. In young infants inunctions of lanolin once a day serve 
the purposes of furnishing a light form of exercise, increasing the periph- 
eral circulation and causing the absorption of small quantities of easily 
assimilable fat. In older children mild exercise in the open air is ad- 
visable. Hydrochloric acid and pepsin given after meals are of value in 
many of these cases. Pancreatin and the thick malt preparations may be 
used to promote the digestion and the absorption of carbohydrate foods. In 
older children nux vomica, in small doses before meals, serves to stimulate 
the digestive capacity. Holt recommends the use of salicylate of soda in 
1- or 2-gr. doses to control gastric fermentation. 



CHAPTEE XIX 

ETIOLOGY AND PEEVENTIVE TEEATMENT OF THE INTESTINAL 
DISOEDEES OF INFANCY 

ETIOLOGY 

These disorders include intestinal indigestion, intestinal intoxication 
and intestinal catarrh. To avoid repetition the etiology and preventive 
treatment of these conditions may be considered under the same heading, 
since they very commonly occur in the sequence given above. The indi- 
gestion may be the initial disturbance which predisposes to the intoxication, 
and the latter very commonly results in intestinal catarrh. These intestinal 
disorders are not sharply defined from each other either in their etiology or 
treatment. On the other hand, they are to a large extent the result of the 
same etiological processes and commonly but different steps in the same 
pathological process, and their treatment is very much along similar lines. 
Kerley has justly laid great stress upon the importance of intestinal indi- 



174 INTESTINAL DISORDERS OF INFANCY 

gestion in predisposing infants to more serious gastrointestinal diseases, 
and German writers, especially Czerny, Keller and Finkelstein, have dem- 
onstrated that the most serious gastrointestinal disorders follow in the wake 
of indigestion produced by overfeeding. The relationship which exists be- 
tween intestinal indigestion, intoxication and catarrh is forcibly brought 
to our minds by the increased death rate of infants during the hot summer 
months. Infants who have suffered from frequent attacks of gastrointes- 
tinal indigestion throughout the year and who have, therefore, feeble di- 
gestive capacities and feeble powers of resistance, are very prone to diar- 
rheal diseases. Infants of this class are often wrongly judged to be in- 
capable of digesting cow's milk and are, therefore, injudiciously placed upon 
more easily digested foods, such as condensed milk, proprietary foods and 
other ill-balanced food formulas, and as a result of such feeding they be- 
come rachitic and otherwise malnourished. With these malnutritions super- 
imposed upon a feeble digestive capacity and feeble powers of intestinal 
resistance, they are ill prepared to stand the dangers from more serious 
gastrointestinal diseases which beset them during the hot summer months. 
The great death rate among weaklings of this class perhaps accounts for the 
rapid increase of infantile mortality from diarrheal diseases in our large 
cities during the early summer months. 

Among the predisposing causes of the intestinal disorders of infancy 
are rickets, syphilis, tuberculosis, anemia, neurotic inheritance, prolonged 
heat of summer and bad hygienic conditions, including impure air and lack 
of sunlight. Any or all of these factors may, by lowering the resistance of 
the infant, reduce its physiological digestive capacity, diminish its tolerance 
for any one of the food ingredients of milk and predispose it to attacks of 
indigestion, intoxication and intestinal catarrh. A feeble, malnourished 
infant that has been getting on fairly well on a carefully modified milk 
mixture may, when the heat of summer lowers its digestive capacity, suffer 
an acute intestinal disturbance caused by the self-same food upon which 
it has been previously thriving. In normal infants a much more potent 
exciting cause, such as overfeeding or contaminated milk, is commonly nec- 
essary to produce intestinal disorders. 

Intestinal disturbances are much less common and much less severe in 
breast-fed than in artificially fed infants. During the first week of life 
indigestion is common, resulting from the physiological incompetency of the 
gastrointestinal canal and abnormalities in the mother's milk; it, as a rule, 
quickly disappears as the intestinal canal adjusts itself to its physiological 
duties and the milk supply of the mother becomes more normal and stable 
in its composition. Later on in the life of the infant, indigestion and diar- 
rhea may result from variations in the fat and protein constituents of the 
milk, produced by menstruation, nervous shock, dissipation, imprudence in 
diet, ill health and the failure to observe proper hygienic rules on the part 
of the mother. These defects are usually transitory and can be corrected 
by regulating the life and diet of the mother ; if not, there is some radical 
defect in the milk and another wet nurse should be secured. There is, 



ETIOLOGY 175 

however, no more common error in infant feeding nor one that is responsible 
for greater loss of life than that of taking infants from the breast for slight 
and remediable causes. 

Overfeeding is the most important cause of indigestion, and the indi- 
gestion thus produced may lead to more serious intestinal disorders; this 
fact has been most graphically pointed out by Czerny and Keller. Very 
pronounced and very persistent gastrointestinal indigestion may result even 
from normal breast milk given in too large quantities and at too short in- 
tervals; but it must be said that the infant shows a remarkable tolerance 
for human milk; it is more difficult to make it ill by overfeeding with 
breast milk than with any other food. The breast milk, however, taken 
in twenty-four hours should not, in caloric value, much exceed the demands 
of the infant, and it should not be given at such short intervals that the 
stomach will not have time to almost or quite empty itself before another 
supply enters it. In America the dangers from overfeeding with breast 
milk are not very great, since American mothers, as a rule, furnish insuffi- 
cient rather than a superabundant supply of milk. This form of indiges- 
tion, if recognized, is easily corrected in the breast-fed infant by allowing 
smaller quantities of breast milk at longer intervals until convalescence is 
established and then allowing it to nurse at regular four-hour intervals. 

In artificially fed infants overfeeding, as a cause of intestinal disorders, 
is much more important and much more serious in its consequences. It may 
produce violent and prolonged gastrointestinal disturbances, which may be 
complicated by intestinal infection and end in enterocolitis. Czerny, 
Keller, Finkelstein and others insist with reason that, apart from a com- 
plicating infection and intestinal catarrh, overfeeding may produce an in- 
jury to the metabolic processes of the infant, manifesting itself at first 
in a severe indigestion and later in fever and profound nervous and other 
constitutional symptoms so severe that it may require weeks of careful under- 
feeding to restore the infant to a normal condition. In most of these cases 
it will be found that the infant has suffered a special "food injury" which 
very markedly diminishes its tolerance for either the fat, the sugar, the salts 
or the proteins of milk, and, in the subsequent feedings, it will be necessary 
for a time to greatly reduce the particular ingredient of the milk for which 
the infant's tolerance has been reduced; this is commonly, early in the 
disease, the fat (cream), and later, the sugar or whey salts. Overfeeding is 
a much more potent cause of indigestion if it be associated with too frequent 
feedings ; the digestive organs of the artificially fed infant must have regu- 
lar periods of rest, and this means feeding at long and at regular intervals. 
Too rapid increase in the strength of the food formula and improper and 
unwholesome food are important causes of indigestion. In the artificially 
fed infant, whatever may be the cause, the results are less serious if it can 
be fed during its convalescence on breast milk. These dietetic errors may 
produce acute intestinal disorders even in normal infants, but they act much 
more rapidly and the symptom complex which they produce is much more 
severe in feeble, malnourished children. 
13 



176 INTESTINAL DISOEDEES OF INFANCY 

The swallowing of mucus, which occurs in catarrhal conditions of the 
respiratory tract in infants, is a very common cause of gastric and intes- 
tinal disturbances. Unwise cathartic medication or drugs, especially those 
belonging to the so-called expectorant class, such as ipecac, squills and 
ammonia, so commonly given to very young infants suffering from catarrhal 
conditions of the respiratory passages, may, if not given with much dis- 
cretion, produce acute intestinal disorders. Dentition and exposure to wet 
and cold may, especially in feeble infants, act as exciting factors of indi- 
gestion and diarrhea. 

In older children much more potent factors than those above named are 
commonly required to produce attacks of intestinal disturbance. They are 
not so easily upset by the quantity of food taken or by eating at irregular 
times provided the food is wholesome, nor are they so easily affected by the 
ordinary bacterial contamination of milk. Indigestion with them commonly 
results from rather gross errors in diet, such as the eating of green fruit 
and large quantities of sweets and pastries. 

Acute intestinal toxemia may come and go without producing acute en- 
teritis, but on the other hand practically every enteritis is preceded or ac- 
companied by a bacterial infection producing an intestinal toxemia and sub- 
sequent catarrh. This, however, does not imply that the initial or most im- 
portant etiological factors of every case of enteritis are bacteria, but it does 
imply that the bacterial factors are all-important in producing the patho- 
logical changes which underlie and prolong these diseases. Acute intestinal 
toxemias are caused by a variety of microorganisms which produce, by their 
action on food stuffs, soluble and irritant poisons. Some of these poisons 
irritate the intestinal mucosa; others are absorbed and exert a poisonous 
action on the nerve centers, especially the anterior horns of the spinal cord. 
In some instances the poisonous bacterial products are formed in such quan- 
tities in milk and other food before they are taken into the gastrointestinal 
canal, that a violent and dangerous intoxication follows directly upon taking 
such contaminated food. These cases are commonly grouped under the 
term "milk or food poisoning," and they have been especially elucidated by 
the researches of Vaughn, who has succeeded in isolating fromi contaminated 
foods soluble poisons, among them tyrotoxicon, by the introduction of 
which into the gastrointestinal canal of animals he was able to produce a 
symptom group similar to that produced by food poisoning. In other in- 
stances — and these are the common ones — the milk at the time of taking is 
so slightly contaminated with pathogenic bacteria that it simply acts by 
starting a pathogenic fermentation in the food contents of the intestinal 
canal of the infant. As this fermentation proceeds, irritant and soluble 
toxins are formed, which sooner or later produce more or less severe symp- 
toms of intestinal irritation and constitutional poisoning. It is also prob- 
able that certain bacteria which are commonly present in the intestinal 
canal of normal infants may, as a result of overtaxing the digestive organs 
with too much food or improper food, become pathogenic, setting up ab- 
normal fermentations which produce irritant and constitutional poisons. 






ETIOLOGY 177 

Since milk is the great carrier of pathogenic bacteria and their soluble 
toxins into the intestinal canal of the infant, it follows that contaminated 
milk is by far the most important cause of gastroenteric intoxication and 
that all of the conditions therefore which predispose to the contamination 
of milk are important etiological factors of this condition. In laying stress 
upon the important role which milk plays as a carrier of pathogenic bac- 
teria, it should not be overlooked that such bacteria may find an entrance 
into the intestinal canal of the infant in other ways ; in the water it drinks, 
on the foreign bodies it puts into its mouth and more especially in the 
mucus which it swallows. I have been much impressed in recent years with 
the fact that too little stress has been laid upon this latter form of contami- 
nation. In catarrhal processes of the nose, pharynx and upper air passages 
which occur in the acute infections, large quantities of mucus are secreted 
and swallowed by the infant. This mucus contains large numbers of strep- 
tococci, staphylococci, influenza bacilli and other microorganisms, which 
may infect the intestinal mucosa or produce a pathological fermentation of 
food stuffs in the intestinal canal, thereby producing an enteric intoxica- 
tion. During the winter season this is perhaps the most important cause of 
this condition; the cases of so-called intestinal grippe and septic enteritis 
follow in the wake of these intoxications. 

Notwithstanding the fact that we speak with such confidence as to the 
role which bacteria play in the production of acute gastroenteric infections, 
yet it must be admitted that, in spite of the enormous amount of work that 
has been done by bacteriologists in the study of the normal and pathological 
intestinal flora, we have not as yet been able to associate definite gastro- 
enteric infections with specific pathological microorganisms, nor is it pos- 
ible for us to say that the normal intestinal flora may not under patho- 
logical conditions play a role in producing these conditions. The intestinal 
canal of the newly born infant is free from microorganisms. Within a few 
hours after birth, however, the normal intestinal flora begin to make their 
appearance, and the character of microorganisms present will depend upon 
the food of the infant. If the infant is breast fed the prevailing types are 
the bacillus bifidus and bacillus acidophilus. The acidouric group, which 
flourishes in carbohydrate media, predominate until the food of the infant 
is changed to cow's milk or until some other albuminous food is added to 
its diet. These acid-forming bacilli protect the nursing infant against at- 
tack from putrefactive organisms. With the change to cow's milk and albu- 
minous food putrefactive bacteria of the colon group having proteolytic 
action make their appearance and in part replace the acid-forming group ; 
this change makes the child more susceptible to intestinal infection with 
pathogenic microorganisms. The important fact to be borne in mind is 
that the bacteria which inhabit the normal intestine serve a useful purpose 
in the digestion of food stuffs, but the most important role that they play 
is in preventing the infection of the intestine with pathogenic bacteria. The 
acid fermentations prevailing in the normal infant's intestines have a ten- 
dency to prevent and destroy putrefactive processes. It is also important to 



178 INTESTINAL DISORDERS OF INFANCY 

bear in mind that the putrefactive processes carried on by pathogenic bac- 
teria in the intestinal canal of the infant may be modified and sometimes 
controlled by a diet poor in albumin and rich in carbohydrates, the carbo- 
hydrate foods favoring the development of some of the normal acid-forming 
intestinal bacteria which have a tendency to destroy the putrefactive bacteria 
flourishing in the proteins. This explains in part the value of carbohydrate 
foods in beginning the treatment of intestinal indigestion; the temporary 
success which follows the use of condensed milk, Nestle's food and other 
foods of this class may be explained in this way. 

Among the pathogenic bacteria which may produce intestinal infection 
the streptococcus enteritidis deserves special mention, and Booker is entitled 
to great credit, since he was the first to call attention to the role which this 
microorganism plays in this condition; he found it not only in the stools, 
but also in the intestinal canal and in the walls of the intestine, and in the 
various organs of infants who had died from acute enteric infection. 
Escherich confirmed Booker's observations and found this streptococcus to 
be the cause of epidemics of this disease, but notwithstanding these observa- 
tions there is no clinical picture which can be definitely associated with 
streptococci. In these conditions it is believed that various species of strep- 
tococci are active. In other epidemics the staphylococcus pyogenes aureus 
and albus predominate. Booker also, in these early valuable researches, 
called attention to the proteus vulgaris as a cause of enteric infection. It was 
associated especially with foul-smelling, constipated, grayish stools cov- 
ered with mucus. Brudzinski later observed that this organism disap- 
peared from the intestine when milk foods were stopped and carbohydrates 
were given, and he also found that the same result could be obtained by 
inoculating the food of the infant with fresh cultures of bacillus lactis 
aerogenes. This is an example of controlling a pathological fermentative 
process by the introduction of bacteria belonging to the normal intestinal 
flora. Escherich, who is one of the most valued workers in this field, de- 
scribes a "blue bacillus/' which he believed to be the etiological factor in a 
severe epidemic of this disease. He also believes, with a number of other 
investigators, that the bacillus coli communis may produce intestinal infec- 
tion. The ameba coli is associated with pathological processes in the infant 
similar to those found in the adult. The influenza or Pfeiffer bacillus is 
now generally recognized as one of the common causes of intestinal infec- 
tion, especially during the winter months. This bacillus may produce a 
more or less severe catarrhal condition of the intestinal mucosa which is 
commonly known as intestinal grippe. The bacillus Welchii, or gas bacillus, 
is believed to be commonly associated with putrefactive intestinal disturb- 
ances. 

In recent years the Shiga bacillus has been definitely associated with 
the etiology and pathology of gastroenteric infections both in the infant 
and in the adult. This bacillus, named for its Japanese discoverer, was 
demonstrated to be the causative factor of epidemic dysentery in the adult. 
Flexner and his associates in this country, and a large number of observers 






ETIOLOGY 179 

the world over, have shown that the Shiga bacillus plays a pathological role 
in the gastrointestinal diseases of infancy, but this bacillus is not asso- 
ciated definitely with any distinct symptom group. It has been found in 
cases of gastroenteric infection and in mild and severe cases of enterocolitis. 
The more recent investigators, however, believe that it is very definitely 
associated with the pathological processes in acute enterocolitis in which the 
stools contain blood and mucus. In some of these cases it is possible to 
demonstrate the specific agglutinin reaction to the Shiga bacillus in the 
blood of the patient. This reaction, it is assumed, definitely associates the 
Shiga bacillus with the pathological process in the intestine. Flexner and 
his associates determined that there were two varieties of the Shiga bacillus. 
One of these, the true Shiga bacillus, is spoken of as the alkaline type ; it 
does not ferment in mannit media ; the other, the Flexner or acid type, 
does ferment in mannit media, and of the two it is more closely associated 
with infantile enterocolitis. But in this disease it is now recognized that 
streptococci and the colon bacillus also enter into the pathological process. 

The infectious nature of the diarrheal diseases of infancy should be 
insisted upon in order to insure proper care in handling the intestinal dis- 
charges. While it is true that there is comparatively little danger that 
bacteria, producing intestinal disorders, will pass directly from one infant 
to another, it is also true that the careless handling of the intestinal dis- 
charges may so contaminate the surroundings of the infant suffering from 
diarrhea that other infants living in the same room will be in great danger 
of gastrointestinal infection. In hospitals and tenement houses infection 
may be a potent factor in spreading the diarrheal diseases of infancy. 

Age is the all-important predisposing cause of the intestinal disorders 
of infancy. The vast majority of these cases occur during the first or 
second year of life. After the second year the predisposition to these con- 
ditions so rapidly diminishes with the age of the child that they are com- 
paratively infrequent, and when they do occur are much less serious in 
character. When it is realized that children three or four years of age, tak- 
ing the same food and living under the same hygienic surroundings, are 
comparatively exempt, the importance of age as a predisposing factor be- 
comes apparent. This susceptibility on the part of infants to gastroenteric 
diseases perhaps may be accounted for by their lack of resistance to fer- 
mentative processes in the intestinal canal and to the resulting catarrhal 
processes which follow these fermentations, and by their greater suscepti- 
bility to the action of soluble bacterial poisons. These soluble poisons, act- 
ing upon the undeveloped and immature nervous system of the infant, pro- 
duce high fever, convulsions, and other severe constitutional symptoms, 
which the better-balanced nervous system of the child resists to such an 
extent that these toxic symptoms are comparatively slight. It follows, 
therefore, that even normal infants should be protected in every possible 
way from all the exciting and predisposing causes of gastroenteric diseases. 

The heat of summer is such an important factor in producing the in- 
testinal disorders of infancy that these conditions are not uncommonly 



180 INTESTINAL DISOEDEES OF INFANCY 

spoken of as "summer complaint." Infant mortality, so enormously in- 
creased during the hot summer months, is largely due to the prevalence of 
gastroenteric diseases during that period of the year. Summer heat pro- 
motes food contamination; among the poor of our large cities who have 
not the means to procure clean cow's milk, nor the facilities for keeping it 
clean even if it were furnished them, milk is so rapidly contaminated by . 
bacteria that it soon becomes an unsafe food for infant feeding, and is 
therefore responsible for a large percentage of the cases of gastroenteric 
infection. Even among the well-to-do, who have the facilities for obtain- 
ing and caring for clean milk, the difficulties which prolonged hot weather 
adds to the care of keeping milk wholesome make milk contamination and 
the resulting intestinal disorders of not uncommon occurrence. The heat 
of summer also acts directly on the infant, diminishing its digestive capac- 
ity and its normal resistance to these diseases. It is also probable, as 
Forchheimer has taught for many years, that many of the cases of so-called 
gastroenteric intoxication are due directly to the effect of heat. That is to 
say, the infant primarily suffers a heat-stroke, with high fever, great pros- 
tration, and secondarily an acute intestinal disorder; the latter condition 
continuing after the infant has recovered from the primary effects of the 
heat stroke. 

Humidity or the amount of rainfall, according to Seibert and others 
who have investigated this subject statistically, has little to do with the 
mortality of this disease, and it is difficult to see how this cause could act 
deleteriously except, perhaps, in housing infants in unhygienic quarters 
on rainy days, and this might easily be offset by the fact that rain cleans 
the air and streets and reduces the temperature. 

Bad hygienic surroundings is an important cause of gastrointestinal dis- 
orders in infancy. This fact is brought home to us by the enormous death 
rate of infants among the tenement house population of our large cities 
during the hot summer months. Infants who must pass their nights in ill- 
ventilated, unclean rooms and their days in the surrounding dirty streets, 
have comparatively little chance to escape the dangers of food contamina- 
tion. Bad hygienic surroundings not only enormously increase the danger 
which surrounds these infants by increasing their opportunities for infec- 
tion, but also predispose them to gastroenteric diseases by reason of the 
fact that they have lived throughout the year in close, badly ventilated 
quarters, with little sunlight and fresh air, and have therefore feeble diges- 
tive capacities and diminished powers of resistance. 

PREVENTIVE TREATMENT 

Since the acute intestinal disorders of infancy are the great causes of 
mortality during this, period of life, every infant should be cared for with 
special reference to the prevention of these diseases. In accomplishing 
this end the physician's prime object will be to place the infant upon the 
most available food for strengthening its digestive capacity and improving 



PREVENTIVE TREATMENT 181 

its nutritional condition. All breast-fed babies should, if possible, be kept 
upon breast milk as an exclusive food during the hot summer months, and, 
if the breast milk be insufficient for this purpose, mixed feeding, as fully 
outlined in a previous chapter, should be resorted to. By this method the 
infant takes sufficient modified milk, following a number or all of the breast 
feedings, to supply its nutritional demands. The importance of a little 
breast milk to assist in the digestion of the cow's milk and to maintain 
the normal intestinal flora is of special importance during hot weather. 
Artificially fed children should be even more carefully fed according to the 
principles outlined under infant feeding. Well infants should be fed at 
regular intervals on a food formula suitable to their age, weight and diges- 
tion, great care being taken, especially in hot weather, not to overfeed either 
in quantity of food taken at a feeding or in the number of calories given in 
twenty-four hours. As the hot weather approaches and the heat increases, 
the normal infant, thriving on a wholesome food formula, should be let 
alone, no attempt being made to increase the strength of the formula or 
to add new foods while the infant is battling with the depressing effects of 
the heat. Be satisfied with having a well baby during the two or three 
months of hot weather even if it gains little or nothing in weight. It is 
wise to discard the scales during this period, lest the ambitious mother at- 
tempt, by the addition or increase of foods, to maintain in the infant the 
same increase in weight which it was making under more favorable con- 
ditions. 

Malnourished, delicate infants with feeble digestive powers are ofttimes 
not able to take the same amount of food during the summer months which 
they have previously thrived upon. With such infants it is wise, therefore, 
as the hot weather approaches, to slightly reduce the amount of fat in the 
food and the quantity of food at each feeding. This precautionary meas- 
ure may prevent indigestion, subsequent infection, and gastrointestinal 
catarrh, and the infant may remain well even though it fails to gain in 
weight. All infants, suffering from rickets and other malnutritions, as a 
result of feeding with condensed milk and the proprietary foods, should 
during the winter months be placed upon a proper milk formula, so that 
their intestinal digestions may be gradually strengthened and educated to 
the digestion of a more wholesome food, which will gradually overcome their 
malnutrition and increase their powers of resistance. These measures will 
better prepare them to withstand the depressing effects of hot weather and 
perhaps enable them to resist the infection to which all are more or less 
exposed. The importance of this line of treatment is recognized, since 
feeble, malnourished infants have much less chance for life when they 
are attacked by these diseases. 

In the prevention of the intestinal disorders of infancy the physician 
should recognize the fact that clean, wholesome food is the most important 
means for accomplishing this end. The basis of all artificially prepared 
infant foods should be clean, raw milk. If this be not possible, pasteurized 
milk, and, where the conditions are such that this is not available, then 



182 INTESTINAL DISOKDEKS OF INFANCY 

sterilized milk. Among the very poor in our large cities it may be neces- 
sary to use condensed milk or the proprietary milk-foods, such as malted 
milk or Nestle's food, for a few months during the summer; the physician 
deciding in the individual case that it is better to expose the infant to the 
dangers of rickets and other malnutritions which result from the continu- 
ous use of these foods, rather than to expose it to the greater danger from 
gastroenteric infections, which will almost certainly result if the infant is 
fed on grocery milk or other cheap grades of milk sold in the tenement 
districts. These milks, greatly contaminated with microorganisms, cared 
for without ice, and handled under unhygienic surroundings, expose the 
infant to dangers from gastrointestinal diseases beside which the malnu- 
tritions coming from ill-balanced, patent, sterile foods are of little conse- 
quence. The use of condensed milk and the proprietary foods may, there- 
fore, be a life-saving measure among the very poor of our cities during the 
months of summer. But if one decides to give an infant rickets and other 
malnutritions in order to save its life, he should also feel the responsibility 
of curing the infant of these malnutritions as soon as the weather con- 
ditions will permit the giving of codliver oil and a return to a wholesome 
milk formula. The necessity for the use of condensed milk and the pro- 
prietary foods among the poor might be greatly diminished if, as Kerley 
suggests, tenement house mothers were furnished with sterilized milk and 
ice to preserve it, and if at the same time they could be systematically 
educated in the care and feeding of their infants. Dr. Wm. H. Park, of 
the New York Health Department, during the summer of 1902, demon- 
strated that this plan was altogether feasible. He selected fifty tenement 
children under one year of age, furnished them with sterilized milk and 
ice, placed them under the supervision of physicians who instructed the 
mothers in the care of the milk and the feeding-bottles, and gave the in- 
fants necessary treatment when they were ill, and as a result all of these 
infants passed through the summer in safety. If our municipal authori- 
ties and organized charities would undertake this same kind of work the 
infant mortality from intestinal diseases during the summer months would 
be materially diminished. 

As heat is so potent a factor in producing the intestinal disorders of 
infancy it follows that all infants during the hot summer months should 
be kept as cool as possible. Among the more prosperous of our population, 
and especially those who live in cities, a radical change of climate is ad- 
visable. When the only thing to be considered is the welfare of the infant, 
it should be sent to some cool country place in our northern country or to 
the mountains or seashore. If this be not feasible it may be taken for the 
summer out of the city into the adjoining country, where the air will be 
purer and cooler and the surroundings cleaner. If this cannot be accom- 
plished it should spend as much of the day as possible out-of-doors on 
porches or in shady yards and parks. In short, it should pass its time day 
and night in the coolest, purest air available. 

Bathing in cool water promotes sleep, acts as a tonic and stimulates the 



SYMPTOMATOLOGY 183 

circulation, and is of great value in preventing gastrointestinal disturb- 
ances. During the very hot weather morning and evening baths are ad- 
visable. The clothing of the infant should be such as not to oppress it, 
and for those infants who are compelled to remain in the city very little 
clothing is needed. Too much clothing is a common cause of overheating, 
skin irritation, sleeplessness, and indigestion, all of which predispose the 
infant to serious gastrointestinal disturbances. Bare feet, legs and arms, 
light napkins, and the thinnest possible covering for the body are all that 
are necessary on very hot days ; on damp and cool days slightly more cloth- 
ing may be needed. The skin irritation which results from heat and heavy 
clothing causes the infant to be restless, irritable, sleepless, and thereby pre- 
disposes it to intestinal disorders. This condition may be corrected by 
clothing and bathing the body as above noted and dusting it with a powder 
made of equal parts of starch and oxid of zinc. 

In the prevention of the intestinal disorders of infancy it is all-im- 
portant that prompt attention be given to the earliest symptoms of gastric 
or intestinal discomfort, If infants had proper medical attention as soon 
as vomiting, diarrhea, or fever appeared, then most of these cases would 
never pass beyond the stage of simple gastric or intestinal indigestion. 
Mothers should be taught that on the appearance of these symptoms a 
cathartic should be given, all food should be stopped, and a physician should 
be consulted. 

CHAPTER XX 
ACUTE INTESTINAL INDIGESTION 

Pathology. — There are no lesions in this disease beyond the temporary 
congestion and irritation of the mucous membrane which result from 
offensive material in the intestinal canal, when this remains long enough 
to produce a catarrhal inflammation we have passed beyond the stage of 
acute intestinal indigestion. The clinician must, therefore, ofttimes await 
the result of twenty-four hours of treatment to determine whether he has 
to deal with an acute intestinal indigestion or an intestinal catarrh. 

Symptomatology. — Very commonly nausea, vomiting, gastric discom- 
fort, and gastric pain may precede the intestinal symptoms. This is es- 
pecially true if the attack be a sudden one, occurring in a normal child, 
produced by some notable error in diet. In feeble infants with weak di- 
gestive capacity, intestinal indigestion usually develops without preliminary 
gastric disturbance. 

Diarrhea is the most common and characteristic symptom, although it 
is not always the first, and constipation may persist throughout the attack. 
Fever and nervous symptoms may mark the onset of the attack, and the 
physician may be in doubt as to the cause of these symptoms until the 
diarrhea assists in making the diagnosis. The very wise and almost uni- 
versal custom of giving a cathartic to a child suffering acutely from fever 



184 ACUTE INTESTINAL INDIGESTION 

and nervous symptoms results in unloading the bowels, and from the 
character of these intestinal discharges the diagnosis is made. The stools 
are commonly alkaline in reaction, green in color, and foul in odor, but 
where they are markedly acid in reaction and sour in odor the diarrhea is 
more pronounced, the constitutional symptoms less severe, and the buttocks 
and adjacent parts red and irritated from the discharges. Mucus and un- 
digested food are present and either small soft curds (fat) or large tough 
curds (casein) may be seen. 

The height of the fever depends largely upon the age and nutrition of 
the infant ; the younger and more malnourished it is the higher the fever. 
The severity of the exciting cause also influences the height of the fever, 
which may vary from 10.1° to 105° F. It falls, however, almost imme- 
diately after the bowels have been unloaded and remains normal under 
proper treatment; its duration should not exceed one or two days. 

The nervous symptoms depend largely upon the age and nutrition of 
the child, as well as upon the severity of the exciting cause. A young, 
feeble, rachitic infant may have a convulsion from an exciting cause that 
could produce only sleeplessness and irritability in an older, normal infant. 
One may say, therefore, that the younger the infant and the more mal- 
nourished it is, the more severe will be the nervous symptoms, which sud- 
denly subside when the intestinal canal is cleared. Following the fall in 
the fever and the subsidence of the nervous symptoms, the child may be 
prostrated and its face show the results of the acute illness of the previous 
day. 

Pain is a frequent symptom. Intestinal colic is especially common in 
young, malnourished infants suffering from attacks of acute intestinal in- 
digestion ; it is produced, as a rule, by flatulency, and the abdomen is there- 
fore more or less distended and tympanitic, but it may also result from 
irregular and excessive peristalsis. In the intervals between the attacks 
of colic, the infant remains quiet for a time and then the paroxysm is re- 
newed; it cries fiercely, draws up its legs, twists its body, and gives every 
evidence that it is suffering great pain. It is also a notable fact that intes- 
tinal colic is a prominent feature of acute intestinal indigestion in older 
children; in these cases the pain may be very severe, the child screaming 
and doubling himself up in his paroxysm of pain, which comes and goes as 
it does in the young and feeble infant. In older children the diarrhea, 
fever, and nervous symptoms are comparatively slight and the patients are 
sleepless, restless, and irritable. The cathartic which carries away the 
offending material commonly relieves all symptoms. 

Symptom Groups. — >Czerny, Keller, Finkelstein, Langstein, Meyer and 
others attempt a differentiation of the symptom groups produced by indiges- 
tion from the different ingredients of milk. These groups represent "food 
injuries" not only to the digestive organs, but also to the metabolism of the 
infant, from the intake beyond the point of tolerance of the fat, carbohy- 
drates, whey salts and proteins in its food. That is, overfeeding with fat, 
carbohydrates, whey salts or proteins produces a distinct symptom complex, 



SYMPTOM GROUPS 185 

which is of great value from a clinical standpoint in that it enables one, in a 
given case, to withdraw from the food the special ingredient causing the 
trouble. If the symptoms indicate fat indigestion, then the fats are to be 
excluded from the diet and the carbohydrates and proteins continued ; if, on 
the other hand, the symptoms indicate a sugar or a protein indigestion, the 
offending ingredient is to be discontinued and the food of the infant made 
up largely of the other two important ingredients. By this method the 
infant will not be unnecessarily starved over a long period of time when 
in fact there is only one ingredient which it cannot digest and properly 
metabolize. There must, however, in these, as in all cases of acute indiges- 
tion, be a period of complete rest and cleansing of the intestinal canal, and 
then the special formula, which the symptoms indicate will be tolerated, 
should be prescribed. It is an interesting fact that, following these "food 
injuries," which are so common in both acute and chronic intestinal indiges- 
tion, the infant's tolerance for the food ingredient which produced the 
injury is very greatly diminished, so that it may be many weeks or months 
before it is again able to digest and metabolize the same quantity of this 
ingredient which it took before the illness ("injury") occurred. For ex- 
ample, an infant that has been thriving upon a food formula which con- 
tained 3 or more per cent, of fat may, following an attack of indiges- 
tion, not be able to take more than % or 1 per cent, of fat ; yet this infant 
may thrive on high percentages of carbohydrates and proteins during the- 
many weeks it is slowly recovering its tolerance for fat (cream). This 
diminished tolerance, which may be so suddenly developed for the food in- 
gredients of milk, is strongly suggestive of the phenomena of anaphylaxis 
and is perhaps similar in its pathology to many of the so-called food idio- 
syncrasies with which we have long been familiar. The poisoning which 
follows the taking of certain foods (such as eggs, fish, etc.) in certain chil- 
dren, and even in adults, is perhaps due to an inherited or acquired lack 
of systemic tolerance for these particular foods. Whatever be the explana- 
tion, the fact remains that intolerance for the various food ingredients of 
milk is very commonly associated with the intestinal disorders of infancy 
and is one of the important factors in aggravating and prolonging them. 
The symptom groups, however, associated with the intolerance of fat, 
carbohydrates, whey salts and proteins are not always clearly defined; this 
is in part due to the fact that different degrees of intolerance for the 
various food ingredients of milk may occur in the same infant, and then 
again it appears that in certain infants the carbohydrates may be tolerated 
when the food has a low fat content, or the fats may be tolerated when the 
food has a low carbohydrate content. The proteins, especially the casein, 
apparently do not aggravate the intolerance of the infant for either fats or 
carbohydrates, but protein intolerance is aggravated by fat and alleviated 
by carbohydrates. The above discussion will, the author hopes, materially 
assist in determining the practical value of the following syndromes. 

Fat Indigestion". — Fat indigestion is very common in the gastroin- 
testinal disorders of infancy, and apart from the ordinary symptoms of 



186 ACUTE INTESTINAL INDIGESTION 

indigestion and intoxication above noted, it has a more or less distinct 
symptom group. There is commonly a history of excessive quantities of 
fat (cream) taken. The infant is malnourished, has a pale, muddy com- 
plexion with dark circles under the eyes, has a coated tongue and fetid 
breath. Gastric disturbance and vomiting are common, constipation is 
nearly always present, but it sometimes alternates with diarrhea. The 
stools are, as a rule, small, fragmentary, dry, and crumbly, and are either 
white or light yellow in color. They may have a shiny, oily look and the 
odor of butyric acid may be noted. A microscopic examination will reveal 
an excess of neutral fats, fatty acids, and soaps. The urine may have an 
ammoniacal odor. An inability to digest and assimilate fat is most com- 
monly associated with acute and chronic intestinal indigestion, the latter 
resulting in marasmus or atrophy. 

Sugar Indigestion. — Sugar indigestion is very commonly associated 
with the gastrointestinal disorders of infancy; in some instances it is the 
important exciting cause, in others it is a contributing factor which aggra- 
vates and prolongs the disease. In these cases there is usually a history of 
an excessive intake of sugars (sweets) ; in young infants milk-sugar is the 
common cause. Diarrhea is the most notable symptom; the stools are fre- 
quent, copious, watery, acid, have a sour odor, and irritate the skin of the 
buttocks; they are usually light green in color and may contain neither 
mucus nor curds; gas formation, producing tympanites, is usually present. 
Vomiting and regurgitation of sour material are common symptoms. The 
infant loses weight, is irritable and fretful, urticaria may occur, and fever 
may be present. The urine may contain lactose, and acetone and diacetic 
acid are frequently found. In older children a sugar intoxication is very 
commonly manifested by an attack of urticaria, recurrent vomiting, mi- 
graine, or asthma, and in such cases the finding of acetone and diacetic 
acid in the urine strongly favors this diagnosis. In severe forms of sugar 
intoxication, described by Finkelstein and others, fever, profound nervous 
symptoms, and a well-marked polymorphonuclear leukocytosis are present. 
In these cases sugar intoxication is commonly associated with an inability 
to metabolize the whey salts, which are believed to be in part responsible 
for the rise in temperature. This group comprehends many of the cases 
which develop into severe intestinal toxemia, the symptom group of which 
is controlled by eliminating the sugars and whey salts from the food, and 
is again aggravated by the addition of these same ingredients. 

Protein Indigestion. — Protein indigestion is not as common as it 
was thought to be a few years ago; it is, however, not infrequent. The 
disturbance is characterized by the ordinary signs of intestinal indigestion 
previously noted. There is commonly a history of an excessive intake of 
proteins, the infant loses in weight, is flabby, anemic, and may have either 
constipation or diarrhea. The stools, however, always contain large, tough 
casein curds; in some cases not more than one or two of these large curds 
are passed in twenty-four hours. The stools are usually alkaline and foul 
smelling. Casein indigestion very commonly leads up to a casein putre- 



TKEATMEJSTT 187 

faction and then we may have the fever, diarrhea, and severe nervous symp- 
toms sometimes associated with this form of intoxication. 

Diagnosis. — The diagnosis of acute intestinal indigestion from acute 
intestinal intoxication and intestinal catarrh is determined by the results 
of the treatment. If the constitutional symptoms yield at once to proper 
cathartic medication and proper diet, the diagnosis of intestinal indigestion 
is confirmed. 

The prognosis is good. In feeble rachitic infants, however, convulsions 
may occur and jeopardize life. When neglected or improperly treated this 
condition may be the cause of an intestinal catarrh or may excite an in- 
testinal toxemia, either of which conditions may place the child's life in 
jeopardy. 

Treatment. — From what has been said it is evident that in feeble, mal- 
nourished children who are markedly predisposed to this disease the pro- 
phylactic treatment is most important. With this type of child the diet 
should be closely watched and regulated to suit existing conditions. The 
food formula should be modified with great care to meet the needs of the 
individual infant, and as the summer approaches special care should be 
exercised to protect it from the depressing effects of the heat. If it be a 
city child it should, if possible, be sent into the country or placed under the 
best possible climatic conditions. 

In dealing with an individual attack a cathartic should be given, and 
of all cathartics castor-oil is preferable. Even if the infant has a disturbed 
stomach and the castor-oil provokes vomiting, the emptying of the stomach 
will be beneficial, and in this event as soon as the vomiting has subsided 
calomel may be given. It is preferable to give the calomel in small doses, 
at frequent intervals, until a grain or a grain and a half has been given, 
and an hour or two after the last dose of calomel a second dose of castor- 
oil may be given. If this is again vomited, milk of magnesia in teaspoon- 
ful doses, at three or four-hour intervals, may be given until the intestinal 
canal is cleared. If, however, the preliminary dose of castor-oil is retained 
no other cathartic is needed. An enema should be given even before the 
cathartic; this is especially indicated if the infant is suffering from colic. 
The injection of water into the colon will, as a rule, unload the lower 
bowel and, in the great majority of instances, relieve the intestinal pain by 
causing a discharge of gas. The enema and cathartic having been given, 
the child is kept as quiet as possible, and if it is still suffering it may have 
dry heat applied to its abdomen ; this may be done with a hot-water bottle, 
the hops bag, or hot flannel. If the feet be cold they also may be warmed 
by the application of dry heat. The cardinal rule in the treatment of these 
cases is absolute rest to the stomach for twelve or twenty-four hours or at 
least until the cathartic has thoroughly acted. Fortunately, in the begin- 
ning the child has no appetite and the thirst which accompanies the fever 
may be satisfied by giving small quantities of water. It is better, however, 
not to begin even the water until two or three hours after the preliminary 
cathartic. The child can, as a rule, be kept upon water for twelve or 



188 ACUTE INTESTINAL INDIGESTION 

twenty-four hours and after this, for the next day, it may be given barley 
water, meat juice, or thin beef or mutton broth. On the third day the diet 
may be whey or fat-free milk in small quantities; the milk should be 
largely diluted, with dextrinized barley water, and the quantity gradually 
increased as the child convalesces. In these cases the tolerance for carbo- 
hydrates and proteins is not reduced, and for this reason most of these 
cases do well upon a mixture of skimmed milk and a thick dextrinized 
gruel until they can gradually be returned to their original food formulas. 
If the symptoms indicate some definite form of food intolerance, a food 
formula very weak in fat, sugars or protein, as the individual case may 
require, may be prescribed. In severe cases the infant may have to be un- 
derfed for a number of weeks before it is finally placed upon a food formula 
suited to its age and weight. 

There is little to add in the way of medicinal treatment for these cases. 
A diastase such as liquid takadiastase may be added to the barley water, 
and simple chalk mixture may be given if gastric or intestinal irritation 
continues. On the fourth or fifth day it is advisable to give a sec- 
ond dose of castor oil, and if this does not produce mucous discharges the 
child may be considered as fairly convalescent. If, however, mucous dis- 
charges are produced by the castor oil, careful dietetic treatment should be 
continued for a few days longer and a third dose of oil given ; these cases 
are bordering on acute intestinal intoxication or catarrh. It is rarely neces- 
sary to use bismuth and never necessary to use opium for the control of the 
diarrhea in acute intestinal indigestion in very young children. The gen- 
eral hygiene of the nursery should be carefully looked to. The infant should 
have all the fresh air it can get without unnecessary exposure, as this is an 
important factor in promoting and restoring good digestion. 

In older children it is necessary not only to give the enema and the 
cathartic and to insist upon abstinence from food, but it is very commonly 
necessary to use opium for the relief of the intestinal pain. This may be 
given in the form of paregoric, and if it be vomited and the intestinal colic 
be severe, a small dose of morphin suitable to the age of the child may be 
given hypodermically. In those cases where opium is used a saline cathar- 
tic is preferable to the castor oil ; sulphate of magnesia will act quickly and 
painlessly in clearing the intestinal canal. After a period of rest to the 
stomach the child may be given broth, toast, malted milk, or some such 
simple food for twelve or twenty-four hours and then gradually return to 
his normal diet. During the attack hot applications to the stomach are 
indicated, even more than they are in the infant, and diastase or a pepsin 
and hydrochloric acid mixture given after meals may hasten convalescence. 



PATHOLOGY 



189 



CHAPTER XXI 

ENTEEIC INFECTION 

(Enterocolitis) 

Enteric infection is a broad term covering the great majority of the 
intestinal disorders of infancy, whose etiology and preventive treatment 
have just been considered. Under this condition may be grouped all the 
intestinal toxemias and intestinal catarrhs. 

Pathology. — The underlying pathological condition is an infection of the 
intestinal canal with microorganisms, producing abnormal fermentations 



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Fig. 28. — Gastroenteric Infection — Mild. 

of its food contents, which result in the formation of soluble and irritant 
poisons. The soluble poisons are absorbed, producing a more or less severe 
systemic intoxication. The irritant poisons produce a congestion and irri- 
tation of the intestinal mucosa, which prepare the way for the microorgan- 
isms to produce more or less destructive lesions of the mucous membrane. 
In the milder cases the mucous membrane is congested, covered with 
mucus, and shows a beginning infiltration with round cells and also a slight 
loss of superficial epithelium. Peyer's patches and the adjacent nodes are 
swollen. As the disease progresses there develops a catarrhal inflammation 
of the mucous membrane of the intestine. The solitary follicles are con- 
gested and may mark the site of small necrotic ulcers, and around them 
superficial ulcers may spread, coalesce, and cover a large portion of the mu- 
cous membrane. In some instances this process is more necrotic, the solitary 



190 



ENTEKIC INFECTION 



follicles breaking down, with the formation of deep, ragged ulcers. These 
are especially located in the colon. The mucous membrane of the colon 
and lower ileum may be covered with a grayish, pseudo-membranous exu- 
date. The spleen and liver may be 
enlarged, the kidneys may show degen- 
erative changes, and the lungs may be 
congested and show patches of bron- 
chopneumonia. 

Symptomatology. — The symptoms 
of this condition fall naturally in two 
groups, namely, those resulting from 
a toxemia produced by soluble toxins, 
and those produced by the intestinal 
irritation and resulting intestinal ca- 
tarrh. These symptom groups, as a 
rule, are inseparably connected, but in 
most cases we have one or the other so 
predominating that one has little dif- 
ficulty in determining whether the 
toxemia or the intestinal catarrh is, 
from the standpoint of immediate 
treatment, more important. The toxic 
symptoms are commonly more pro- 
nounced at the onset, and later the 
symptoms of intestinal catarrh or en- 
terocolitis predominate. But through- 
out the course of this disease, in most 
instances, the toxic and catarrhal symp- 
toms are so intermingled that they 
form a clinical picture which prac- 
tically needs not be further subdivided 
into syndromes. 

This disease is commonly marked 
by fever, nervous symptoms, vomiting, 
diarrhea, and more or less prostration, 
and it may vary in gravity from rap- 
idly fatal cases of so-called cholera in- 
fantum, where the toxemia is so vio- 
lent that catarrhal lesions have hardly 
time to develop, to mild infections 
showing but slight fever and nervous 
symptoms accompanied by a slight diarrhea. 

The fever, which is one of the earliest symptoms, varies with the sever- 
ity of the infection; it may rise within the first twenty-four hours to 104° 
or 105° F. It commonly continues, except in the mildest cases, for four or 
five days, and during this time it is markedly influenced by the action of 



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SYMPTOMATOLOGY 191 

cathartics. As the intestine is unloaded of its poisonous contents the tem- 
perature falls sharply, perhaps rising again to be again lowered by cathar- 
tic medication. If the fever continues beyond the fifth or sixth day one 
may conclude that catarrhal lesions in the intestine have formed, and the 
disease from this time on presents more marked symptoms of enterocolitis 
and, in favorable cases, less marked symptoms of toxemia. The persistence 
or return of well-marked toxic symptoms in these cases is a very unfavor- 
able indication. 

Vomiting is usually the symptom which calls attention to the child's 
illness. It occurs in a large percentage of the cases and may be most dis- 
tressing and troublesome during the first twenty-four or forty-eight hours. 
Within this time under appropriate treatment the vomiting disappears and 
does not commonly return, but when it does return it is an unfavorable in- 
dication, as it generally means an increase in the intestinal toxemia. The 
diarrhea which occurs in this disease is, like the vomiting, an effort on the 
part of nature to get rid of the poisons in the gastrointestinal tract. The 
earlier the diarrhea appears the better for the patient, as it reduces the 
fever and other toxic symptoms. This eliminative diarrhea usually begins 
on the second day. The fecal discharges vary greatly in different cases; 
they are commonly foul in odor, discharged with flatus, green in color, and 
contain mucus and undigested food. The number of discharges may vary 
with their size; in some instances being small and frequent, in others 
copious and discharged at intervals of four or five hours. In this disease, 
above all others, it is important to bear in mind that the diarrhea, espe- 
cially during the first few days, is a life-saving measure, which is to be 
encouraged by proper medication. If constipation be present, as it is in 
some cases, then the vomiting and constitutional symptoms are aggravated 
and the necessity for unloading the bowel more urgent. As the catarrhal 
process becomes more marked in the colon and in the lower ileum the in- 
testinal discharges are then made up largely of bloody mucus, which is 
passed with more or less pain and straining and the number of stools may 
be as high as twenty or thirty in the twenty-four hours. This character of 
stool occurring in a child acutely ill and having an elevation of temperature, 
whether it occurs early or late in the disease, indicates that the infection 
has produced an enterocolitis. It should, however, be noted that blood in 
the stools does not always mean intestinal ulceration ; if transitory in char- 
acter it commonly means a simple catarrhal process with marked conges- 
tion. On the other hand, it should be noted that marked ulceration may 
occur without blood showing in the stool at any time. The diagnosis of 
ulceration of the bowels, however, may be assumed if the fever and muco- 
purulent discharges, tinged or not with blood, continue for ten days or two 
weeks. Prolapse of the rectum is not uncommon in these cases and in rare 
instances a pseudo-membrane may be seen on the prolapsed rectum. Small 
pieces of pseudo-membrane may also be found in the stool. These appear- 
ances are the only positive indications of the presence of a pseudo-mem- 
brane in this disease. 
14 



192 ENTEBIC INFECTION 

The nervous symptoms are most important and their severity will de- 
pend upon the virulence and amount of soluble toxins absorbed from the 
intestine, and upon the susceptibility of the individual infant to the action 
of these poisons. Kestlessness, fretfulness, muscular twitchings, somno- 
lence, stupor, convulsions, delirium, unconsciousness, and finally paralysis 
of vital centers resulting in death may occur. In severe cases a peculiar 
nervous syndrome closely resembling meningitis may be present. Here the 
stupor and convulsions may be associated with retraction of the head, stif- 
fening of the muscles of the neck, irregular pulse and respirations. These 
symptoms continuing for days, with fever and increasing coma, may be 
distinguished from meningitis by the fact that they are associated with the 
character of diarrhea previously described, and by the absence of charac- 
teristic findings in the cerebrospinal fluid obtained by tapping the spinal 
canal. Since this nervous syndrome is not associated with meningeal le- 
sions it is perhaps produced by the action of toxins on the nerve centers. 
In severe cases emaciation is extreme, the eyes are sunken, the fontanels 
depressed, and the infant may die from exhaustion or pass into an atrophic 
condition from which it requires months, if not years, to recover. For- 
tunately, however, the majority of the cases of intestinal infection are of 
moderate severity and associated with a mild form of toxemia. In these 
cases the nervous irritability, muscular twitchings, mental stupor and fever 
gradually subside. The blood, if present, disappears from the stool, but 
the mucous discharges continue with more or less tenesmus for six or seven 
days, with gradual improvement until they become normal at the end of 
the second or third week. 

Urticaria, erythema, and other toxic rashes are very common, especially 
in the milder cases. 

The general appearance of the infant is an indication difficult to de- 
scribe, but one that impresses the physician almost more than any other 
with the seriousness of this disease. The character of the prostration, the 
facial expression, the extent of the emaciation and the mental alertness of 
the infant vary in the production of a picture, which greatly assists the 
physician in making his prognosis in individual cases. 

Cholera infantum represents the most severe type of acute enteric 
infection. It has no distinguishing characteristics except the suddenness 
of its onset and the severity of its symptoms. This clinical syndrome 
resembles in some particulars that of true cholera, and it has, therefore, 
been dignified by the title cholera infantum. It usually occurs in non- 
resisting weaklings, but may occur in normal infants. It is believed to be 
a food poisoning commonly produced by badly contaminated milk; the 
infant gets such a large initial dose of toxins that it is almost im- 
mediately overwhelmed by the toxemia. The choleriform diarrhea pro- 
duces more rapid emaciation and loss of weight than any other dis- 
ease of infancy. The stools are large, frequent, and watery in char- 
acter and this violent purging is accompanied by severe vomiting. 
The temperature commonly reaches 104° or 105° F., continues high 



TREATMENT 193 

for twelve or twenty-four hours, and then falls with the collapse 
and prostration of the . infant. The surface temperature is cold, while 
the rectal temperature, in the rapidly fatal cases, may register 107° F. 
Stupor, convulsions, and coma, following each other in rapid succession, 
may mark the progress of the disease, which may terminate fatally within 
twelve hours, but which commonly lasts for three or four days. Under 
proper treatment some of these cases, especially those occurring in previ- 
ously normal children, may recover. 

Prognosis. — Other things being equal, the younger the infant the more 
unfavorable the prognosis. The prognosis also depends upon the severity 
of the enteric infection, the resistance of the individual infant, the hygienic 
surroundings, and the character of the treatment instituted. On the whole, 
however, except in cholera infantum, the prognosis is good, since the vast 
majority of these cases are produced by infections so mild that they are 
readily controlled by appropriate treatment. The continuous presence of 
bloody mucus in the stools for weeks indicates ulceration in the bowels, 
which means either an unfavorable prognosis or a very slow recovery. 

Treatment. — As this condition in the beginning is essentially an acute 
intestinal poisoning, the all-important indication (except in those cases of 
the cholera-infantum type) is to cleanse the intestinal canal as rapidly as 
possible. With this end in view the colon should be irrigated and imme- 
diately thereafter a dose of castor-oil or sulphate of magnesia given; 
the oil is to be preferred unless the stomach be very irritable. If 
the oil or magnesia is rejected by the stomach, it should be allowed 
to rest for half or three-quarters of an hour and then washed out 
with a solution of sodium bicarbonate, a teaspoonful to the quart. Half an 
hour following this irrigation calomel should be administered, one-quarter 
of a grain combined with one grain of sodium bicarbonate, every half-hour, 
until two grains have been given. After the preliminary cathartic has 
cleared the intestinal canal there is commonly no further vomiting and all 
the toxic symptoms, including the fever, are much modified in their 
severity, but in the event that the, vomiting continues to be a troublesome 
symptom, the stomach may be washed out with normal salt solution every 
six to twelve hours for the first twenty-four or thirty-six hours. Luke- 
warm baths, sponging with cool water, and ice caps to the head are valuable 
measures in the control of fever and nervous symptoms during this stage 
of the treatment. 

Diet. — It is evident that in a disease where the unloading and cleansing 
of the intestinal canal are of such vital importance, it must be equally 
important that during the first few days little or no food should be 
given. During the first twenty-four hours only water should be given; 
during the second twenty-four hours weak tea is an excellent substitute 
for food. Alcohol in the form of good whiskey or brandy may also be 
given in from 15- to 30-drop doses, well diluted, every three or four hours, 
provided the stomach is in a condition to retain it. During the third 
twenty-four hours, if the infant be breast-fed, it may be allowed to nurse 



194 ENTEKIC INFECTION 

at intervals of five or six hours, until it has been demonstrated that the 
breast milk will not cause a return of the symptoms, and within the next 
few days it may have the normal quantity of breast milk. In artificially 
fed infants, which make the great majority of the cases, the infant may 
on the third day be given barley water, toast water, or a weak lamb or beef 
broth. In very young infants the barley water should be dextrinized, as 
undigested starch is not easily assimilated at this age. By the fourth day, 
if the case has progressed favorably and the fever and other toxic symptoms 
have subsided, one part of skimmed milk mixed with four parts of dex- 
trinized barley water may be given. If this agrees, the skimmed milk and 
beef or lamb broth may gradually be increased in quantity until convales- 
cence is thoroughly established, and then the infant should be gradually 
returned to its original diet. In more severe cases, after the acute symp- 
toms of the disease have been controlled, and the infant still has unhealed 
ulcers in its intestinal canal and a feeble digestive capacity, the skill of the 
physician will be taxed to give it food which will sustain it and at the same 
time will not cause relapse. Breast milk is the safest and best of all foods 
to accomplish this result. If a wet-nurse cannot be obtained Finkelstein's 
albumin milk, or the curd from a pint of cow's milk which has been finely 
disintegrated by passing it through a sieve two or three times, may be 
added to a pint of equal parts of skimmed milk and barley water, and one 
or the other of these foods be given in proper quantities until the symptoms 
of intoxication and intestinal irritation have subsided. Fresh buttermilk, 
and the buttermilk and malt soup formulas elsewhere described are useful 
in some cases. 

The principles of importance in the dietetic management of these cases 
are: 

First. — Starvation for a variable length of time, depending upon the 
severity of the case; during this time albumin water and beef juice, so 
commonly recommended, are not to be given. In fact, these albuminous 
foods are especially contraindicated at this time, and continue to be until 
the putrefactive processes in the intestine have been controlled. 

Second. — Breast milk is by far the best food in these cases, but early 
in the disease it should be given in small quantities and at long intervals. 
If artificial food must be used it should be poor in milk and cane sugars and 
whey salts and rich in casein. Weak carbohydrates, such as barley water, 
dextrinized gruels, and dextri-maltose foods may be used to dilute the 
casein mixtures. These foods may be inoculated with lactic acid bacilli so 
that they may act as the breast milk does by increasing the normal intesti- 
nal flora j which antagonize the pathogenic flora which have taken posses- 
sion of the intestinal canal. Fresh buttermilk acts in the same way. 

Third. — As the convalescence of the infant is established, the food is to 
be very gradually increased by the substitution of ordinary milk formulas. 
There is great danger of reinfecting the intestinal canal by overtaxing it, 
especially with whole milk, lactose, saccharose and whey salts. 

Fourth. — In more severe cases, where the disease is prolonged by catar- 



TBEATMENT 195 

rhal or ulcerative processes in the colon and lower ileum, the dietetic treat- 
ment is much more prolonged and difficult, and a wet-nurse is not only 
advisable but absolutely necessary to successful convalescence. If a satis- 
factory wet-nurse cannot be obtained then a very slow return to the original 
diet will be necessary, and this period may extend not only over weeks but 
over months. 

Medicinal Treatment. — Other medical treatment than that above 
given for cleansing the intestinal canal may be of value in individual cases, 
but it should not interfere with the preliminary cathartic medication and 
should not, as a rule, be begun until the second or third day. To allay the 
gastric and intestinal irritation 3- to 5-grain doses of equal parts of com- 
pound chalk powder and guaiacol carbonate may be given every three or 
four hours, and a day or two later for the relief of the same symptoms, one 
may substitute for the above prescription 1 or 2 grains of salol and 3 to 6 
grains of subnitrate of bismuth given in one-half-teaspoonful doses of 
simple chalk mixture. If the diarrhea persists and the disease becomes 
less acute, the doses of bismuth may be increased to 10 grains every four 
hours. Diastase aids the digestion of carbohydrate foods, and hydrochloric 
acid and pepsin, taken after eating, assist in the digestion of milk and 
other protein foods and are of value during convalescence. 

Morphin in 1-50 to 1-100-grain doses is a remedy of great value for 
controlling convulsions where simpler measures fail, while the fact should 
be impressed that morphin given in this way may be a life-saving meas- 
ure, yet it should also be noted that the practice of giving morphin for the 
control of convulsive disorders may be abused and may result in harm to 
the infant. In the severe cases, however, where the convulsions are con- 
tinuous, this is practically the only remedy that can be relied upon. Holt 
recommends 1-50 grain of morphin and 1-600 grain of atropin, to be given 
hypodermically, to "neutralize the effect of poisons on the heart and nervous 
system in cases of the cholera infantum type." This use of morphin is 
almost the only indication for the opium preparations in the treatment of 
acute gastroenteric infections; it is perhaps never necessary to give opium 
to infants under one year of age for the control of the diarrhea or for the 
relief of pain or other intestinal symptoms ; the indiscriminate use of pare- 
goric and other opium preparations given by the mouth to relieve pain and 
diarrhea, increases the mortality in this disease. In older children, after the 
acute symptoms have subsided, the opium preparations, especially paregoric 
and Dover's powder, may be of value in relieving the pain and tenesmus 
which occur when the catarrhal condition becomes localized in the colon. 
But even in these cases they must be used with great discrimination, if good 
rather than harm is to result from their use. Colon irrigations are of 
special value in those cases which, as shown by the large quantities of 
mucus they pass, have catarrh or ulceration of the colon, and, as the object 
of these irrigations is largely to remove the mucus and otherwise cleanse 
the diseased mucous membrane without irritating it, there can be little 
doubt that lukewarm normal salt solution will serve this purpose best. 



196 ENTERIC INFECTION 

Irrigations of a sufficient amount of this fluid to fill the colon may be given 
from one to three times in twenty-four hours. If the infant does not re- 
spond kindly to these injections or shows prostration or intestinal irritation 
following their use, they may be discontinued. Such unfavorable symp- 
toms, however, are more commonly due to faults of technique than to the 
injections themselves, and there can be no doubt but that on the whole 
they are a very valuable aid in the treatment of this disease. In the event 
that catarrh or ulceration of the colon continues for weeks after acute con- 
stitutional symptoms have disappeared, good may then result from astrin- 
gent injections of alum or tannic acid (one drachm to the quart of water), 
following the cleansing of the membrane with normal salt solution. Castor- 
oil is the cathartic par excellence, not only in the beginning but through- 
out the course of this disease. It is especially valuable in those cases char- 
acterized by the passage of frequent, small, mucous stools ; not only in these 
cases, but in all it is to be repeated every third or fourth day unless it be 
contraindicated by the condition of the stomach or some idiosyncrasy on 
the part of the child. No other laxative acts so kindly in carrying off the 
mucus and relieving the complicating toxemia as does castor-oil. If some 
other laxative must be used, then Eochelle salts, the milk or sulphate of 
magnesia may answer the purpose. 

Stimulating Treatment. — Stimulating treatment by hypodermic 
medication may be a life-saving measure in very severe cases. If, for 
example, during the first few days, when it may be impossible to give stimu- 
lants by the mouth, the infant should be threatened with symptoms of col- 
lapse, hypodermic stimulation is not only advisable but is ofttimes abso- 
lutely necessary. The most valuable stimulant we possess is normal salt 
solution (45 grains of sodium chlorid to 1 pint of sterile water). This 
should be given by hypodermoclysis, 6 to 8 ozs. at six-hour intervals. The 
salt solution is rapidly absorbed, acts as a general stimulant, furnishes 
fluid to the body media, and assists in the elimination through the kidneys 
of the absorbed toxins which produce such a profound influence upon the 
nervous system. Caffein sodium benzoate in % to %-grain doses may be 
given hypodermically. Camphor and ether are valuable stimulants and 
may be used as directed in the following prescription modified from 
Forchheimer : 

Jl Camphorae 25 grs. 

Olei amygdalae express % oz. 

M. Five to ten minims hypodermically. 

JJ Camphorae 25 grs. 

^Ether 2 drachms 

Olei amygdalae express 2 drachms 

M. 5 to 10 minims hypodermically. 

The above hypodermic medication is especially valuable in the treatment 
of cases of cholera infantum. By these measures the life of the infant may 
sometimes be prolonged until the vomiting and diarrhea subside, permit- 
ting the administration of water and stimulants by the mouth. 



CHEONIC INTESTINAL INDIGESTION IN INFANTS 197 

Hygienic Treatment. — The hygienic treatment of these cases is of 
the utmost importance. While acute symptoms threaten the life of the 
child it should be kept at home and there placed under the most favorable 
hygienic conditions possible. Many infants are rushed away from their 
homes when acutely ill with enterocolitis, with the idea that cool, pure 
country air is of more importance than skilful medical attention and care- 
ful nursing in the treatment of this disease. Many such infants subjected 
to long railroad journeys die on the road or soon after they have reached 
this a ideal climate," where perhaps they have not found good medical at- 
tention and skilful nursing. Home is the place to begin the treatment of 
acute enterocolitis and the treatment should there be continued until the 
acute symptoms are under control and the infant is in a condition to travel 
without danger of a relapse; then it should be sent for its convalescence 
to some bracing climate where it can have pure cool air. 



CHAPTEE XXII 

CHRONIC INTESTINAL INDIGESTION 
(Chronic Enterocolitis, Infantile Atrophy, Marasmus) 

CHRONIC INTESTINAL INDIGESTION IN INFANTS 

Etiology. — The general etiology of this condition has been previously 
outlined; here, however, certain factors prominent in the chronic forms of 
intestinal diseases are emphasized. Age is an important predisposing fac- 
tor; most of these cases occur in infancy, but they are not uncommon in 
the child. Among predisposing causes the following may be noted : Hered- 
ity, rickets, anemia, tuberculosis, syphilis, general malnutrition, and previ- 
ous intestinal attacks. The infant may inherit from weak and neurotic 
parents a physiological incapacity to digest ordinary food. The heat of 
summer, impure air, and dirty surroundings are most potent factors in 
producing chronic gastrointestinal disturbances. 

The exciting causes are to be found in the food. If the disease occurs 
in breast-fed babies it is due to overfeeding, too frequent feedings, or to 
some fault in the breast milk. Improper artificial feeding is, however, the 
cause in the vast majority of cases. Too much food, in ounces given at a 
feeding and in the number of calories in twenty-four hours, overtaxes the 
digestive powers of the infant and produces repeated attacks of acute in- 
digestion and intoxication, which in time so diminish its normal digestive 
capacity that it is in a more or less constant state of intestinal indigestion. 
The infant, after repeated attacks of acute intestinal indigestion, very com- 
monly has its digestive capacity for fat and whey salts very much low- 
ered. Wholesome food, therefore, given in too great quantities or con- 
taining too many calories or given at irregular intervals, may, after a time, 
produce chronic intestinal indigestion. Food spoiled by bacterial contami- 



198 



CHRONIC INTESTINAL INDIGESTION 



nation is the most potent cause of this condition ; it acts by causing repeated 
attacks of acute intestinal infection which in time produce chronic in- 
digestion. 

Pathology. — The underlying condition is a pathological digestive in- 
capacity which makes it impossible for the infant and child to digest, as- 
similate, or metabolize the ordinary food suitable to its age and weight. 
The degree of this incapacity determines the seriousness of the condition. 
In many cases there is present a low grade of intestinal catarrh, so that 
these cases might properly be classed as chronic enterocolitis. But from a 
clinical standpoint this differentiation is not important since the treatment 
is the same. 

Symptomatology. — Profound increasing malnutrition associated with a 

chronic diarrhea is the 
most characteristic symp- 
tom. The number of dis- 
charges in the diarrheal 
cases may be many or 
few in a day; they con- 
tain mucus, curds and 
undigested food, are com- 
monly green in color, 
and may be either foul 
or sour in odor; they are 
passed with flatulence, 
but there is little pain. 
The buttocks may be ir- 
ritated or excoriated from 
the discharges. The stools 
usually contain neutral 
fats, fatty acids and 
soaps, and the curds are 
commonly small and 
soft; tough, large, casein 
curds holding in their meshes large quantities of fat are also frequently seen. 
Those cases in which the diarrhea is a marked symptom are commonly due 
to an incapacity to digest sugars and fats. In other cases constipation may 
be a marked symptom and it may alternate with diarrhea. In the con- 
stipated cases the stools are commonly gray or white in color, of a putty- 
like consistency, covered with mucus, and have a foul odor ; there is usually 
more or less fever, colic, and nervous symptoms. No hard and fast lines 
can be drawn separating the diarrheal from the constipated cases, either in 
their symptomatology or their etiology, since in the same infant the two 
symptom groups not uncommonly alternate ; but the dry, putty-like, putrid, 
constipated stool is commonly associated with fat indigestion, and the co- 
pious, watery, frequent, diarrheal stools, sour in odor, discharged with flatus 
and irritating to the buttocks, are usually associated with sugar indiges- 




Fig. 30. — Casein Curds, Actual Size. (Talbot.) 



CHRONIC INTESTINAL INDIGESTION IN INFANTS 199 



tion. Protein indigestion may be associated with either of these symptom 
groups. Fever is commonly absent; subnormal temperatures are common. 
Fever, however, associated with other acute symptoms, is an indication 
that an intestinal infection, or an acute intestinal indigestion, is compli- 
cating the chronic process; this not infrequently occurs during the pro- 
longed course of a chronic intestinal indigestion. Nervous symptoms are 
more marked in the constipated cases. The appetite is usually good, the 
infant very commonly empties its bottle and cries for more ; this appetite 
far beyond its digestive 
capacity is a source of 
great trouble, since the 
mother and sympathetic 
relatives are led to be- 
lieve that the infant is 
being starved, and, as its 
appearance carries out 
this inference, it is often 
difficult to feed it within 
the range of its digestive 
capacity. The urine usu- 
ally contains indican or 
indolacetic acid and ace- 
tone may be present. 

Infantile Atrophy. 
— The common causes of 
this condition are pre- 
maturity, chronic tuber- 
culosis, syphilis, chronic 
intestinal indiges- 
tion, chronic enteroco- 
litis, improper food, 
faulty methods of feed- 
ing or an hereditary 
physiological incapacity 
of the digestive organs. 
It is largely an institu- 
tional disease, occurring especially in artificially fed children. Wentworth 
believes it is due to "a defective correlation of the several digestive organs, 
stomach, intestines, pancreas and liver," which results in disturbed diges- 
tion and feeble assimilation of foodstuffs. Edsal has demonstrated the ab- 
sence of digestive ferments in some of these cases. Finkelstein and other 
German writers believe that it is largely due to an inability of the infant 
to digest and assimilate fat (cream), and the whey salts. 

The symptomatology in its early history is commonly that of intestinal 
indigestion. With the progress of this disease the infant loses in weight, 
becomes anemic, malnourished, rachitic, and finally profoundly emaciated. 




Fig. 31. — Infantile Atrophy. 



200 CHRONIC INTESTINAL INDIGESTION 

The picture presented by advanced atrophy is truly a pitiful one ; the face 
is thin, wistful, senile, the eyes are sunken in their sockets, and the fon- 
tanels depressed; the neck, arms, and legs are atrophied; the subcutaneous 
fatty tissue having disappeared, the dry skin hangs in loose folds over the 
bony structures and a general edema may be present. The abdomen is dis- 
tended and tympanitic, and the bones of the chest and back stand out promi- 
nently beneath the skin which enfolds them. In these advanced cases the 
stools may be apparently normal, but a microscopical examination, as a 
rule, shows undigested food, with an excess of neutral fats, fatty acids and 
soaps. 

Prognosis. — The prognosis of intestinal indigestion depends upon the 
length of time the disease has lasted, the degree of malnutrition it has pro- 
duced and, above all, on the amount of injury which has resulted to the 
infant's digestive and assimilative capacity. In severe cases which have 
reached the stage of "atrophy" the prognosis is very grave, in the milder 
cases there is a fair chance of recovery; in all cases the convalescence is 
slow, and success largely depends upon the physician's ability to impress 
upon the attendants the necessity for long-continued attention to the 
minutest details in the care and feeding of the infant. 

Treatment. — In beginning the treatment of chronic intestinal in- 
digestion a dose of castor-oil should be followed by abstinence from food 
for a period of twelve or twenty-four hours, and the infant should then be 
given the following dietetic treatment : 

Dietetic Treatment. — In the beginning the mother should be told 
that the object of the dietetic treatment is to find a food that can be 
digested and assimilated in small quantities, and that the evidences of suc- 
cess in treatment will be manifested by the improvement in and gradual 
return to normal of the intestinal discharges and by the infant beginning to 
hold its own in weight, but that under no conditions is it expected to gain 
in weight for some weeks to come. Such an understanding is necessary 
in order to have the co-operation of the mother and nurse throughout 
the long and tedious treatment. Human breast milk is the most valuable 
of all foods in the treatment of these cases and should, therefore, be used 
when it can be obtained ; it is absolutely necessary in the worst cases, those 
approaching the atrophic type. In these cases of infantile atrophy it 
may be necessary to resort to small feedings of skimmed breast milk to give 
the nutritional processes a start, and then continue the dietetic treatment 
with small quantities of whole breast milk nursed from the breast at long 
intervals. The success which sometimes follows the feeding of these ap- 
parently hopeless cases of atrophy with human milk depends partly on the 
fact that it contains certain ferments which assist in its own digestion, and, 
since the fat of the milk is the most potent disturbing factor in these 
cases, the fat-free mother's milk is the ideal food with which to begin the 
feeding. The second important fact to be remembered is that whatever 
food is taken it must in the beginning be given in very small quantities, 
2 to 4 ounces at four-hour intervals, and only very gradually increased when 



INTESTINAL INDIGESTION IN OLDEK CHILDREN 201 

it has been demonstrated that it has been digested and assimilated. Water 
may be given in the intervals between the feedings. 

When breast milk is not available the infant should be placed upon a 
fat-free milk, peptonized for twenty or twenty-five minutes, and then placed 
on ice without heating. When fed it should be diluted one-half with boiled 
water, to which lime water has been added. After a week or ten days a 
dextrinized gruel may take the place of the water in the above mixture. 
The fat-free peptonized milk and dextrinized gruel mixture, if it agrees 
with the infant, should be gradually adjusted, in ounces given at a feeding 
and in calories given in twenty-four hours, to suit the weight of the indi- 
vidual infant. After some weeks, if the infant is progressing favorably, 
small quantities of fat may be gradually added to the food. This is best 
done by skimming the milk a little less closely. Slowly the fat is, in this 
way, returned to the food formula and then, perhaps after months of treat- 
ment, the milk is slowly depeptonizecl. That is to say, the peptonizing 
process is carried on for a shorter time and with less peptonizing powder 
until, in the course of a few months, it is discontinued. 

Finkelstein's albumin milk, buttermilk, and malt soup formulas are of 
value in the treatment of many of these cases. Beef juice, whey, and albu- 
min water may be used to supplement the diet when other foods are given at 
long intervals. In the convalescence from this condition the general rules 
previously outlined under Infant Feeding should be followed. 

Hygienic. — Fresh air and a suitable climate are very necessary to suc- 
cess. During the hot summer months these patients should, if possible, be 
sent out of the city to a cool country place in the north or to the mountains 
or seashore, where they may live out-of-doors. These delicate, malnour- 
ished infants, when kept out-of-doors, often require artificial heat in the 
form of hot-water bottles to keep their bodies and extremities warm. They 
also require quiet surroundings so that they may have all the undisturbed 
sleep possible, and regular bathing for its stimulating and tonic effects. 

Medicinal. — The medical treatment is of secondary importance. When 
fever or nervous symptoms develop a laxative such as castor-oil or milk of 
magnesia should be given and the following prescription used : 

Jfy Misturse cretse > § j 

Liquid taka-diastase | { 

Sig. One-half to one teaspoonful with each feeding. 



CHRONIC INTESTINAL INDIGESTION IN OLDER CHILDREN 

Etiology. — This condition is exceedingly common and is frequently 
overlooked, being mistaken for some functional nervous disorder. Its 
underlying cause is usually a carbohydrate intolerance; it is aggravated 
and prolonged by the excessive use of sugars and starchy foods, especially 
potatoes. The use of candies, sweets of all kinds and other foods unsuited 
to the child's digestive capacity are potent factors. Eating between meals 



202 CHBONIC INTESTINAL INDIGESTION 

and at irregular intervals will aggravate and prolong the disease. It occurs 
very commonly between the ages of three and eight, and is more frequently 
seen in neurotic children suffering from other constitutional diseases. 

Symptomatology. — These children are neurotic, malnourished, thin, 
anemic, and delicate in appearance. They have little powers of resistance, 
and, when fatigued, have dark circles under their eyes. Their appetites are 
poor and capricious; nausea, vomiting and fever may occur from slight 
causes; the tongue is coated, thick and flabby; the breath at times has an 
acetone odor. They are usually constipated, have large distended abdo- 
mens, with more or less marked tympanites. The intestinal discharges pro- 
duced by laxatives or enemata consist of undigested fecal masses, mixed 
with mucus and fluid matter of foul odor. The stools may be white or dark- 
brown in color, with a coating of mucus as their distinctive characteristic. 
Following a cathartic, such as castor-oil, the mucus is passed in large 
amounts. The urine may contain acetone or diacetic acid, and almost 
always has an excess of indican or indolacetic acid. The nervous symptoms 
are very pronounced; they constitute, in fact, the symptom group which 
calls attention to the child's illness. The child is irritable, fretful, sleeps 
badly, dreams and cries out in its sleep, and frequently has night-terrors. 
Fainting spells, asthma, severe headache and even convulsions, resembling 
epilepsy, may occur. The following case illustrates a severe type of this 
condition. 

Boy, age five years, had never been strong, had stomach and intestinal 
trouble very frequently during his life, was thin, anemic and malnourished. 
During the past year he had been very nervous. This nervousness increased 
so that he was irritable, cried on the slightest provocation, was very restless 
at night, and had certain peculiar nervous attacks. These attacks came on 
suddenly with dizziness, the boy fell to the ground, his mother thought that 
he did not lose consciousness, was sure that he had no convulsive move- 
ments, and some minutes elapsed before he was able to regain his feet ; they 
were followed immediately by severe headache, more or less nausea, and a 
profound sleep which lasted some hours. From this sleep he awoke quite 
as well as before the attack. Seven of these attacks occurred during the past 
year, and they increased in frequency and severity. They apparently occu- 
pied the border line between migraine and epilepsy. This boy suffered 
more or less constantly from constipation, abdominal distention and flatu- 
lency. The constipation at times, however, gave way to an attack of diar- 
rhea. He had no fever, and his mother said she fed him almost anything 
he would eat, "because he ate so little that it could not hurt him \" The 
urine was highly colored, had a specific gravity of 1.023, contained no albu- 
min, no sugar, but there was a marked excess of indican. This boy promptly 
recovered under treatment. 

Intestinal indigestion in the older child is frequently associated with 
constipated, mucous, foul-smelling, undigested stools, and is characterized 
by intestinal toxemia, profound nervous symptoms, great excess of indican 
in the urine and progressive failure in general health. These cases, not 



INTESTINAL INDIGESTION IN OLDEE CHILDREN 203 

associated with diarrhea and intestinal pain, are most commonly over- 
looked. 

Prognosis.— This is good under proper treatment. The disease, how- 
ever, is essentially a chronic one, and it should be understood in the begin- 
ning that it will require many months, perhaps years, to restore the child 
to perfect health. 

Treatment. — This is chiefly dietetic. It is most important that the 
child should eat suitable food at proper intervals, taking absolutely no food 
between meals. From three to four meals a day should be prescribed, de- 
pending upon the age and digestive capacity of the individual child. Food 
should be eaten slowly, well masticated, and violent exercise directly after 
eating should be avoided. The following foods are especially contraindi- 
cated: cakes, candies, sweets of all kinds, an excess of starchy foods, 
potatoes, hot breads, fried foods, pastries, and raw fruits. In some 
cases, especially those in which the stools are white and fragmentary, 
all fats, such as butter, cream, fat meat and codliver oil, are to be excluded 
from the diet. The following foods may, as a rule, be recommended : beef, 
lamb, chicken, fish, eggs, peptonized milk, skimmed milk, malted milk, beef 
juice, broth, toast, a small quantity of bread, and certain well-cooked ce- 
reals, such as rice, cream of wheat, oatmeal, farina, arrowroot and tapioca. 
In taking these cereals as little sugar as possible should be used, and they 
should be covered with milk rather than with cream. As the child con- 
valesces stewed celery, carrots, asparagus tips, peas, beans, orange juice, 
baked apples, and prune juice may be allowed. This diet should be perse- 
vered in for many months, and above all sweets and potatoes should be 
excluded until convalescence is established. 

A suitable climate, in which the child may live and sleep out of doors 
and take exercise in the fresh air, will greatly hasten convalescence. 

Medicines play a useful role in the treatment of this condition. The 
careful choice of laxatives is important. A dose of castor-oil is occasionally 
necessary, especially when acute symptoms develop. It is most important 
that the bowels should be moved daily. This may be accomplished by milk 
of magnesia, cascara, or at times by saline enemata. The injection at bed- 
time of one to three ounces of olive oil into the rectum, as recommended by 
Kerley, is very valuable. Systematic massage is also valuable in overcoming 
constipation. Hydrochloric acid and pepsin taken after meals are of value 
in some cases. The thick malt extracts containing diastase are especially 
useful in promoting the digestion of the carbohydrates. In some instances 
nux vomica and the organic iron preparations may be combined with the 
malt extracts, to the advantage of the patient. With the judicious use of 
these measures chronic intestinal indigestion in the older child can be suc- 
cessfully treated, provided the physician is content to go slowly with his 
dietetic treatment, and provided he has an ever-watchful mother or nurse 
to see that the details are carried out. 



204 CONSTIPATION AND DILATATION OF THE COLON 



CHAPTER XXIII 

CHEONIC CONSTIPATION IN INFANCY AND CONGENITAL 
DILATATION OF THE COLON 

CHRONIC CONSTIPATION IN INFANCY 

Etiology. — There is on the whole a natural predisposition to constipa- 
tion in infancy which is in part counteracted by mother's milk and is aggra- 
vated, as a rule, by the ordinary modified milk formulas used in artificial 
feeding. This predisposition lies largely in the fact, as Jacobi has so clearly 
pointed out, that the colon is relatively longer in the infant than it is in 
the adult, and that especially the sigmoid flexure runs a winding con- 
voluted course with a long mesenteric attachment. This condition of the 
colon in infancy furnishes a suitable reservoir for the collection and reten- 
tion of fecal matter. As the child grows older and its body increases in 
size, the sigmoid flexure becomes less convoluted and gradually approaches 
the condition found in the adult. 

Eickets, anemia, and especially long-continued intestinal fermentation 
result in a weakening and thinning of the muscular fibers of the intestines, 
which interfere with normal peristalsis and lead to dilatation of both 
the small and large gut, thus producing a condition of muscular atony, 
which is a very common cause of constipation in infancy. Heredity may 
be an important etiological factor. Constipation is not infrequently a 
family disease. Functional incompetency of the liver, occurring periodically, 
may aggravate a mild into a very obstinate constipation. The temporary 
absence or deficiency of bile produces dry, putty-like, putrid movements, 
and this intestinal condition is associated with lack of appetite, coated 
tongue, bad odor of the breath, and in older children headache and nausea. 
Constipation is also common following the acute infectious diseases, and 
especially so during and following an attack of meningitis. Diseases of 
the rectum, such as fissure and hemorrhoids, may produce a reflex spasm 
of the sphincter muscles and may cause the child to resist as long as pos- 
sible the desire to go to stool. Simple non-incarcerated hernia may also be 
a cause. Pyloric stenosis and inflammatory bands produced by peritonitis 
may cause serious forms of constipation. The frequent use of purgative 
medicines, especially castor-oil, may be a factor in converting a simple into 
a chronic constipation. Irregularity as to time in evacuating the bowels, 
which results from lack of proper training of infants and young children, 
and from the haste of older children to go to school in the morning and 
their confinement during school hours, is a cause of constipation. 

Dietetic causes are more important than all other factors in producing 
this condition. In breast-fed babies constipation most commonly results 
from insufficient food and from a low percentage of fat in the milk. The 
mother's milk may be modified to overcome this condition by placing her 



CHKONIC CONSTIPATION IN INFANCY 205 

under proper hygienic conditions and regulating her diet according to the 
principles elsewhere outlined. In artificially fed infants the sterilization 
and pasteurization of milk and the giving of easily digested carbohydrate 
mixtures, weak in fat and proteins, are common causes of constipation. In 
older children the feeding of easily digested foods, such as milk, eggs, meat, 
cereals, white bread, toast and broths, to the exclusion of fruits and veg- 
etables, is a potent factor in producing this condition. 

Symptomatology. — Constipation is determined, not by the number of 
stools, but by the character of the discharges. The normal infant may have 
from one to four soft evacuations in the twenty-four hours, but when con- 
stipated the stools are composed of hard, dry, round or fragmentary fecal 
masses passed with difficulty and with more or less straining and tenesmus. 
These discharges may occur two or three times in the twenty-four hours 
or an interval of days may elapse between them. The fecal masses may 
also be covered with mucus and stained with blood. The infant loses its 
appetite, is restless, sleepless, nervous and irritable ; it has attacks of colic 
with abdominal distention ; it may surfer from frequent attacks of intestinal 
indigestion with vomiting, fever and severe nervous symptoms, even con- 
vulsions. This latter symptom group is due to the intestinal toxemias pro- 
duced by the constipation and occurs especially in rachitic, malnourished 
infants. In these cases an increase in the indican in the urine may be a 
valuable indication of the onset of an intestinal toxemia. 

In older children an excess of indican or indolacetic acid in the urine is 
a more valuable indication of the extent of the putrefaction going on in the 
intestine. The intestinal toxemia which results from the constipation is 
not infrequently the cause of a more or less profound malnutrition and 
anemia, especially of the chlorotic type. These children may also suffer 
not only from colic and indigestion, but frequently from obscure nervous 
symptoms such as headache of the migrainous type and attacks of "recur- 
rent vomiting." Vertigo and temporary loss of consciousness may form the 
nucleus of a symptom group, which may ultimately develop into epilepsy if 
the constipation and resulting intestinal toxemia are not relieved. 

In both infants and older children fissure and prolapse of the rectum, 
and hemorrhoids may result from chronic constipation and may then aggra- 
vate the condition. 

Diagnosis. — The diagnosis of constipation, as the all-important cause 
of a severe nervous syndrome or of a profound anemia, may sometimes be 
overlooked, especially in older children. It is therefore important for the 
physician to keep in mind the fact that such severe symptom groups may 
have their origin solely in a chronic constipation. A careful examination of 
the abdomen may reveal in these cases impacted fecal masses in the colon. 
This examination should never be omitted in any case of constipation, how- 
ever mild it may appear. It is also important before beginning the treat- 
ment that the cause of the constipation should be made out. The family 
history as to heredity should be carefully noted. The rectum should be 
examined for local disease and the genitalia for sources of reflex irritation ; 



206 CONSTIPATION AND DILATATION OF THE COLON 

phymosis is of special importance. These abnormalities about the rectum 
and genitourinary organs may locate the cause of the constipation. The 
form of constipation which occasionally results from an excess of cream in 
the infant's food should also be kept in mind; in this condition the stools 
are gray, dry, fragmentary and putrid. It is also most important to de- 
termine whether an atonic condition of the intestine is the cause of the 
constipation; in these cases the abdomen is distended with gas, the infant 
is anemic or rachitic, and enemata are not effective in unloading the bowels ; 
an active cathartic, however, with temporary abstinence from food relieves 
the distended intestine and flattens out the abdomen. 

Treatment. — Treatment in Infancy. — It should be understood in the 
beginning that constipation, especially in the artificially fed infant, is so 
common that one may almost consider it the normal condition, and it should 
also be understood that this mild form of constipation occurring in infants 
under one year of age cannot, as a rule, be altogether cured by diet, It 
must therefore be relieved by the introduction into the rectum of an oiled 
catheter or a gluten suppository, or a small quantity of normal salt solution 
or olive oil. At this age glycerin and soap suppositories should not be 
habitually used, as they may produce local disease of the rectum and thus 
aggravate and complicate the constipation. Medicines are also of value, 
especially the milk of magnesia, which may be used occasionally to supple- 
ment the local measures above described. Castor-oil is contraindicated un- 
less an intestinal intoxication with fever and constitutional symptoms 
complicate the constipation. Diseases of the anus and rectum should be 
relieved by appropriate treatment. 

The dietetic treatment is important. Eaw, clean milk should be sub- 
stituted for sterilized milk; where this is not possible pasteurized milk 
should be used. Oatmeal water, or dextrinized gruels may be used as a 
diluent for the milk; any time after the sixth month orange juice 
may be given to the normal infant, beginning with the juice of half 
an orange once in twenty-four hours. The use of cream mixtures, which 
has been so widely recommended, is attended with some danger; there can 
be no doubt, however, but that, in infants having a normal digestive ca- 
pacity for fats, cream, provided it is clean and wholesome, may be added 
to advantage in small quantities to the milk formula. An infant under six 
months of age should, however, not exceed 3 per cent, of fat and in older 
infants the fat percentage should not go above 4 per cent. The thick malt 
extracts, such as maltine, maltzyme and Trommer's malt, are much more 
valuable in the treatment of constipation in infancy than cream, and they 
are not attended with any danger. They may be given in the nursing 
bottle ; for infants three months of age one and a half teaspoonfuls, and 
at one year of age four teaspoonfuls in the twenty-four hours. With this 
treatment it is commonly possible to control constipation during the first 
year of life, but it should ever be kept in mind that if constipation at this 
age cannot be relieved by simple means it is better to temporize, awaiting 
the time when the infant is able to take other foods for a permanent cure 



CHKONIC CONSTIPATION IN INFANCY 207 

of the condition. Many vigorous, healthy infants have been made ill by 
strong medicines or by feeding cream in too large quantities or by using 
other foods beyond the digestive capacity of the infant. 

Treatment During the Second Year. — Dietetic. — All the measures 
above noted may apply in the treatment of constipation during the second 
year. Orange juice may be used in larger quantities, cream may be given 
with less danger, and cooked fruits, such as apple sauce made from ripe 
apples, and prune juice, may be allowed. Whole wheat bread, well buttered, 
may be added to the diet and in the latter part of the year fresh, well- 
cooked green vegetables may be given. 

In older children raw and stewed fruits suited to the age and digestive 
capacity of the child should be prescribed. Bran biscuits, whole wheat 
flour, unstrained oatmeal with butter and cream and a liberal supply of 
fresh vegetables should form part of the diet, and the child should be in- 
duced to take large quantities of water between meals. Abdominal massage 
is of great value, especially in older children ; it should be of such a char- 
acter that it will give tone to the abdominal muscles, stimulate peristalsis 
and facilitate the emptying of the colon and sigmoid flexure. An active 
outdoor life or gymnastic exercises under a satisfactory tutor should be in- 
sisted upon. In obstinate cases Kerley recommends the introduction of 
four to six ounces of warm olive oil at bedtime; the oil is to be introduced 
high up into the sigmoid flexure and is to be retained during the night; 
if necessary a napkin can be used to prevent the child from soiling the bed. 

Medical Treatment. — Olive oil or codliver oil, combined with one of 
the thick malt extracts, may be used to great advantage, especially after 
the first year of life. * Calomel and sodium phosphate may occasionally 
be necessary for the relief of acute conditions which may arise. The so- 
dium phosphate is especially valuable in children over two years of age 
with a gouty or bilious diathesis, suffering from hereditary constipation. 
In these cases a saturated solution of phosphate of soda may be given in 
milk. Sulphate of magnesia and Eochelle salts, like castor oil and rhubarb, 
are of value only in beginning the treatment of aggravated cases or for 
relieving acute intestinal symptoms which may develop during the treat- 
ment. Cascara is the cathartic of greatest value in the treatment of con- 
stipation in older children; the aromatic cascaras on the market are, for 
the most part, reliable; they should always be given at bedtime and an 
effort should be made, as time goes on and other treatment is instituted, 
to gradually reduce the dose. In carrying out this treatment the child 
should be made to use the chamber at a regular time every morning, and if 
at the expiration of fifteen minutes a satisfactory evacuation has not re- 
sulted a gluten suppository or a small salt water injection should be given. 
In this way the habit of going to stool at a regular hour will be established 
and this will do much to complete the cure of the constipation. The habit 
of regular evacuations at regular hours should be begun in early infancy; 
it may sometimes be accomplished when the child is six months of age, but 
from the end of the first year it should be an important part of the routine 
15 



208 CONSTIPATION AND DILATATION OF THE COLON 

treatment and should be insisted upon long after the constipation has been 
cured. In connection with this method of training and the use of cascara, 
nux vomica or strychnin may be employed; 4 drops of nux vomica or 1/100 
grain of sulphate of strychnin, given three times a day before meals, is a 
suitable dose for a child six years of age. These drugs, if dissolved in 
equal parts of sherry wine or essence of pepsin, are not unpalatable. 

J^ Strychnin sulph % gr. 

Sherry wine 2 ozs. 

Ess. pepsin 2 ozs. 

Sig. Teaspoonful before eating for child six years of age. 

This prescription may be continued for many weeks, and in the mean- 
time the cascara, which is being given in very accurate and just sufficient 
doses to produce a normal evacuation, is gradually diminished. 



CONGENITAL DILATATION OF THE COLON 

Etiology. — Congenital dilatation of the colon is a rare disease which 
may manifest itself in two rather distinct clinical types. 

First, the condition described by Hirschprung in 1880. It has its 
origin in a congenital malformation of the colon which manifests itself 
by clinical phenomena directly after birth. The colon is elongated, con- 
voluted and much dilated and its walls are commonly hypertrophied. This 
condition leads to the accumulation and retention of the meconium and 
other fecal matter and to a subsequent gaseous fermentation, which results 
in distending and further dilating the colon. From time to time during the 
progress of this disease bacteria may cause- putrefactive processes which 
may result in a general systemic intoxication. 

The symptom group in these cases is very characteristic. The infant 
at birth may not appear abnormal, since its intestinal canal is free from 
bacteria and fermentative processes, but as soon as it commences to take 
food abdominal distention appears and the attendants note the fact that 
the bowels have not been evacuated. Eectal injections may cause the dis- 
charge of gas and small quantities of fecal matter. The escape of gas flat- 
tens the intestine, but the dilatation of the abdomen very shortly returns 
as a result of the gaseous fermentation going on in the colon. The infant 
fails to thrive and, as a rule, continues to grow weaker, since in these cases 
it is practically impossible to keep the colon evacuated and control the 
fermentative processes. As time goes on, if the infant lives, the distention 
of the colon becomes so great that it may be outlined against the enormously 
distended abdomen, and the fecal masses, removed by cathartics and ene- 
mata, are covered with mucus and have a putrid odor. Sooner or later — 
it may be weeks and it may be many months — the infant gradually suc- 
cumbs from inanition or intestinal intoxication. The latter may produce 
stupor, coma and convulsions. 






CONGENITAL DILATATION OF THE COLON 209 

The second group of cases also has its origin in a congenital malforma- 
tion of the colon, which is apparently a great exaggeration of the physi- 
ological condition found in infancy, namely, the long-convoluted, freely 
movable sigmoid flexure and descending colon. The fecal material accumu- 
lates in this reservoir and undergoes a gaseous fermentation, and later 
putrefactive processes may cause intestinal toxemia and start catarrhal 
processes in the mucous membrane of the cecum, which may end in ulcera- 
tion and abscess. The differentiation of the two types of congenital dila- 
tation of the colon lies largely in their symptomatology and the time in the 
life of the infant when the first symptoms are made manifest. 

Symptomatology. — An infant, that has not perhaps thrived well from 
birth, at the end of the third or fourth month of life develops a very marked 
constipation associated with abdominal distention. As time goes on the 
constipation becomes more aggravated and the colonic distention becomes 
greater, so that the syndrome produced gradually comes to resemble that 
of the first group of cases which occurs directly after birth. This second 
group of cases, however, occurring in older infants, is not so severe in its 
onset and. not quite so serious in its nature. The enormous dilatation of 
the colon, which in time results, is not altogether congenital, but is for the 
most part brought about by fermentative processes in the sigmoid flexure. 
Gradually the colon becomes so enormously dilated that it distends the 
abdomen to such an extent as to interfere with the action of the diaphragm, 
even producing dyspnea and cyanosis. As the disease progresses it be- 
comes a more and more difficult matter to unload the colon, and the fecal 
matter discharged contains more mucus and is more putrid. The intestinal 
toxemia and inanition present in these cases materially assist in producing 
the emaciation, the progressive anemia, asthenia and the severe nervous 
symptoms, such as coma and convulsions, which may mark the downward 
progress of the disease. A most satisfactory demonstration of the enlarged 
colon can be made by X-ray pictures, after giving large doses of subnitrate 
of bismuth; by this method the size and position of the colon can be 
made out. 

Prognosis. — The prognosis is bad, only about 10 per cent, of the cases 
reported have recovered. The disease may be prolonged for a number of 
years ; the majority of cases, however, die before the end of the second year, 
but some of the milder ones assume a chronic form and may live for eight 
or ten years. The prognosis in the chronic cases is slightly more favorable. 

Treatment. — The medical treatment is very unsatisfactory. The prime 
object is to sustain and nourish the child, if this be possible, by giving it 
the foods most suitable to its age and condition. In the acute cases oc- 
curring just after birth, or within a few months thereafter, breast milk is 
the only food to be considered. If the infant live, however, longer than 
one year the dietetic treatment is to be the same as that outlined under 
Chronic Indigestion. The next indication is to relieve the gaseous disten- 
tion of the colon by the introduction of a rectal tube and to keep the bowels 
open and the colon as well washed out as possible by mild laxative medica- 



210 INTESTINAL PARASITES 

tion and by enemata. In early infancy the most appropriate laxative is 
the milk of magnesia. In the milder and more chronic cases that live to be 
over two years of age the cascara preparations are more appropriate. The 
daily use of salt water enemata, for the purpose of unloading and cleansing 
the colon, is necessary throughout the course of the disease. In addition 
to these measures the chronic cases may be benefited by massage and elec- 
tricity. The massage should begin at the cecum and end at the sigmoid 
flexure, its object being to unload the colon and to give tone to its muscular 
coats. Faradization of the large intestine has also been recommended; in 
applying electricity both electrodes may follow the course of the large in- 
testine as outlined through the abdominal wall, or one may be inserted 
into the rectum and the other be applied to the abdomen over the course 
of the large intestine. Tincture of nux vomica or strychnin may be used 
as a tonic in association with the cascara preparations as directed under 
the treatment of chronic constipation. The permanent cure of these cases, 
however, can be hoped for only by operative measures; they may be 
greatly benefited by the establishment of an artificial anus above the point 
of greatest colonic distention. This surgical procedure, by largely putting 
out of function the diseased portion of the colon, enables it to partially re- 
cover its tone, and the subsequent final cure of these cases is to be hoped 
for in the closure of the artificial anus and turning the fecal stream again 
into the colon, which rest, massage and electricity have placed in a more 
normal condition. Resection of the diseased portion of the colon itself may 
be made; this operation, however, has not been tried often enough to de- 
termine its ultimate value. 



CHAPTER XXIV 

INTESTINAL PAEASITES 

Within the last fifty years in this country, worms have, both to the lay 
and the medical mind, been losing their importance as pathological factors. 
This is largely due to two reasons. First, with an advancing civilization 
there has come a higher average of personal and household cleanliness and 
more sanitary methods of disposing of fecal matter; these improvements 
in the hygienic surroundings of children have actually diminished the per- 
centage of cases. Second, with an advancing knowledge of diseases of chil- 
dren physicians have learned that the vast majority of symptom groups, 
which were formerly thought to be due to worms, can now be associated 
with other definite pathological conditions, and that, with the exception of 
the hook-worm, these intestinal parasites rarely cause serious or pronounced 
constitutional symptoms. 






INTESTINAL CESTODES 



211 



INTESTINAL CESTODES 

(Tenice, Tapeworms) 

Varieties. — The following varieties of tapeworm are found frequently 
enough in children to deserve study : the tenia saginata, the tenia solium, the 
tenia elliptica, the hymenolepis nana, and the bothriocephalus latus. 

Tenia Saginata. — The tenia saginata, or beef tapeworm, is the form 
most commonly seen in this country. This worm may be over twenty feet 
in length, beginning with a small square head, 2 to 3 mm. thick, at the 
corners of which are suckers containing circles of pigment. With these 
suckers, which are very powerful, the worm fastens itself to the mucous 
membrane of the intestine. Behind the head is a still thinner neck, which 
gradually widens out, presenting a tape-like appearance. The body of this 
tapeworm is divided into segments, which when sexually mature are ap- 
proximately 18 mm. long and 7 mm. broad. Each matured segment is 
filled with a uterus, having a central canal with branches like a tree ex- 
tending in every direction. These uteri when filled with eggs are very 
easily discerned, but in the mature segments which have been broken oif 
from the worm and been discharged the eggs are not very plentiful. The 
eggs are oval or round, have a brownish-yellow color, but no very distinctive 
individual characteristics. Infection occurs from eating beef containing 
this parasite. The life cycle of this tapeworm, as of all others, passes 
through three stages — the egg, the embryo and the worm. The eggs are 
passed with the segments from the intestinal canal of the human being 
and contaminate the pastures or other food material of cattle. The cattle 
taking these eggs into their intestinal canals, they are 
there developed into the embryo. This embryo, 
which contains the fully developed head of the 
tapeworm, escapes through the intestinal wall and 
lodges in the muscles and other tissues of the animal 
and there becomes encysted, producing a cysticercus. 
Cattle thus infected and their meat also are said to 
be "measly." This "measly" beef containing the 
embryos, if taken in a raw or imperfectly cooked 
state, passes into the intestinal canal and there the 
embryo may fasten itself by its suckers to the walls 
and draw therefrom its nourishment as it gradually 
grows into the fully developed tapeworm. 

Tenia Solium. — Tenia solium, or pork tape- 
worm, has a very small head with four suckers and 
a rostellum surrounded by a double row of hooks, 
20 to 30 in number. With these hooks as well as with its suckers the 
pork tapeworm attaches itself to the mucous membrane much more firmly 
than does the beef tapeworm. Behind the head is a very thin neck passing 
into a tape-shaped body that is divided into segments, which when mature 




-Tenia Sagi- 
(Strumbell.) 



212 



INTESTINAL PARASITES 



are 10 mm. long and 6 mm. broad. The fully developed worm may be 20 
feet in length. The uterus, which fills the matured segments, differs from 
that of the beef tapeworm in that its central canal is heavier than its 
branches heavier and more irregular in form. The eggs are globular with a 




Fig. 33. — Scolex, Egg and Ripe Segments of Tenia Solium. (Wood.) 

diameter .03 mm. The life cycle of this tapeworm is similar to that of the 
beef tapeworm except that its embryo stage is passed in the hog. Infection 
therefore occurs from eating raw pork. 

Hymenolepis Nana. — Hymenolepis nana, or the dwarf tapeworm, is, 
according to Schloss, a common intestinal parasite in children. He found 
it in 14 out of 230 dispensary patients. Its average length is 14 to 16 mm. ; 
its distal half is broad, its proximal half narrow. The segments are 3 to 6 
times as broad as they are long; the head is globular, carries four suckers 
and a rostellum with twenty or thirty bifid hooklets. Its eggs are slightly 
oval and have two widely spaced membranes. From the inner membrane 
filaments spring which ramify in the space between the membranes. The 
habitat of this tapeworm is the upper two-thirds of the ileum. Six of the 
fourteen cases presented no symptoms ; in the remaining eight the symptoms 
were similar to those produced by other tapeworms. 

Bothriocephalus Latus. — Bothriocephalus latus, or fish tapeworm, 
has an oval-shaped head with two elongated depressions serving the pur- 
pose of suckers, which attach it to the intestinal canal. It is the largest of 
all the tapeworms, reaching a length of 30 or 40 feet. The segments or 
links are only 5 mm. long and about 14 mm. wide, making a characteristic 
differentiation between this and other tapeworms. The slight length and 



INTESTINAL CESTODES 213 

great breadth of these segments present to the naked eye a characteristic 
picture. The uterus is simpler in form, having only 5 or 6 branches. The 
eggs are oval, yellowish-brown in color, are .07 mm. long and .045 mm. 
broad, and they have at their top a peculiar cap or lid which has the appear- 
ance of closing the egg cavity. The life cycle of this worm is the same as 
other tapeworms except that its larval or embryo stage is passed in the 
body of certain fishes ; the pike, the perch, the trout, and the salmon are its 
most common hosts. Infection occurs from eating raw fish thus infected. 
This worm is most common, therefore, among the fish-eating population 
along the lakes and seashore. 

Tenia Elliptica. — Tenia elliptica, or the dog or cat tapeworm, has 
upon its head four suckers and a rostellum with fifty or sixty hooks which 
enable it to attach itself most firmly to the mucous membrane of the in- 
testinal canal. Its links are 8 mm. long and 2 mm. broad. These long and 
narrow links differentiate it from other tapeworms. It passes its larval 
stage in the lice of the house-dog or cat, and these insects are swallowed by 
these animals and can be conveyed to children who play with them. This 
worm is not of common occurrence, but the great majority of the cases oc- 
cur in children. 

Symptomatology. — The habitat of the full-grown tapeworm is in the 
intestine, and the vague symptom group which it causes comes largely 
from the irritation which it there produces. Indigestion, nausea, head- 
ache, nervous irritability, sleeplessness, and in rare instances more severe 
nervous symptoms may result. This symptom group, however, has nothing 
whatever characteristic in it, since in the majority of instances it is almost 
or quite absent, the child appearing in normal health. In a very small per 
cent, of the cases of Bothriocephalus latus there occurs a very severe form 
of anemia. Eosinophilia and a mild simple anemia occur in nearly all chil- 
dren who have had tapeworm for any length of time. 

Diagnosis.- — Diagnosis in nearly every instance is made by seeing the 
segments of the worms in the stools. The parents or nurses can scarcely 
overlook for any length of time the tapeworm segments; as they mature 
they are broken off and escape by the rectum. The cases, therefore, come 
to the physician with a diagnosis made. If, however, there be any doubt 
an active cathartic may be given to carry away segments of the worm. Fail- 
ing in this the fecal matter may be examined microscopically for the eggs. 

Differential Diagnosis.— The differential diagnosis of the varieties of 
tapeworm can, as a rule, be made by carefully studying the ripe segments, 
and may be of considerable importance, especially between the tenia solium 
and the tenia saginata, the two most common varieties. If the tenia solium 
be present the treatment is more urgent and should be more energetic, since 
it fastens itself more tightly to the intestinal canal by hooklets, and there is 
also greater danger in this form from cysticerci or the encysted embryos, 
which may result from the eggs of tenia solium, finding their way into the 
stomach. In such instances the child becomes the intermediary host, and 
the embryo, formed in its intestinal canal from the egg, passes through the 



214 INTESTINAL PAEASITES 

intestinal wall and finds a lodgment in the muscles, brain, or other organs, 
where it may produce disease even after the intestinal canal of the child 
has been entirely cleared of tapeworms. 

Treatment. — The remedies used for the treatment of tapeworm are 
more or less toxic and more or less irritating to the gastrointestinal canal. 
They should therefore be used with caution, and in every case the question 
must be decided whether the child is in a proper physical condition to 
undergo the treatment. In all cases where the child is acutely ill from 
other diseases, especially from gastrointestinal troubles, and in all cases 
where it is weak and malnourished from some other chronic disease, it is 
better to postpone the treatment until it can at least be put in a fair con- 
dition of health. During this time the child should, at intervals of four or 
five days, be given doses of castor oil for the purpose of breaking off sections 
of the worm and discharging them. In this way the intestinal irritation 
may be modified and the danger of cysticercus minimized. 

The Cure. — After a day of preparatory treatment, during which the 
child has little to eat and is given at bedtime a saline laxative, the medi- 
cines for stupefying and expelling the worm are given early the next morn- 
ing on an empty stomach. In this country the oleoresin of aspidium (filix 
mas) has been very generally and very successfully used. It is perhaps the 
most satisfactory of all remedies. It should be given in doses of from 7 to 
30 minims, depending upon the age of the child. In infancy it is advisable 
to begin with from 5- to 7 -minim doses ; if this treatment fails, at its next 
administration the dose may be increased ; for a child three years of age 10 
to 15 minims may be given; for a child six years of age 30 minims. Two 
doses of the size above noted should be administered, one when the child 
awakens in the morning and one an hour later. The child should then be 
kept as quiet as possible without food. Four or five hours after the last 
dose of male fern a saline laxative should be administered. This is to be 
preferred to castor oil, as it is less likely to provoke vomiting and as there 
is a suspicion that oil increases the toxic action of filix mas. One or two 
hours after the laxative small quantities of food in the form of beef broth 
may be commenced. This treatment commonly results in the expulsion of 
the entire worm. A careful examination should be made by the nurse of 
the fecal matter expelled and every particle of the worm carefully saved for 
the physician's examination. The object of this examination is to find the 
head of the tapeworm ; if this be found a cure may be assumed, since, as a 
rule, only one worm is present at a time. If the head is not found one is 
always in doubt, and two weeks later the same treatment may be repeated. 
If the head is not then found it is advisable to wait until time determines 
whether the child has been cured or not. If after a number of weeks the 
segments again appear in the stool, the same treatment is repeated, giving 
one-third larger dose of the male fern. It is not commonly necessary to 
repeat this cure again, since this treatment in the great majority of in- 
stances is successful. Following the giving of the male fern and the 
cathartic, the child should for a few days be carefully dieted to avoid gastro- 



ASCAEIS LUMBRICOIDES 215 

intestinal irritation. The best form for administering oleoresin of aspidium 
will depend upon the age of the child. If the child is old enough it may be 
given in capsules, if not, in an emulsion of equal parts of gum tragacanth 
and simple elixir. A favorable vehicle is thus offered for the administration 
of a drug which not only is very distasteful to the child, but may produce 
nausea and vomiting and thus necessarily postpone the cure. 

Prophylactic Treatment. — As rare beef, and beef juice made from 
raw beef, are such common articles of diet with young children, it is wise 
to explain to parents that there is a slight danger of contracting tapeworm 
from eating these foods. This danger can be removed by stopping these 
foods and permitting children to have only beef, pork and fish that have 
been well cooked, or it may be minimized by carefully scrutinizing all meat 
for cysticerci, before preparing raw foods for children. This latter method 
of prophylaxis with reference to rare beef and beef juice is to be advised 
because there is only the slightest possible danger, with this precaution, that 
the child may contract tapeworm, and the disease itself is not of sufficient 
seriousness to warrant the elimination from the child's diet of two of the 
most important foods during this period of growth and development. 
Nevertheless, as a fundamental principle of prophylaxis one should advise, 
with these exceptions, that all meat foods should be well cooked. 

To prevent the spread of this disease by those infected, it is necessary 
that their fecal discharges be carefully disposed of. In the city this may 
be done by giving great care to the personal cleanliness of the child, burn- 
ing the segments as they appear in the stools, scalding out all vessels used 
for the reception of fecal matter, and flushing the feces into the sewer 
as soon as possible. In the country, where sanitary plumbing is not used, 
it is best to burn all fecal discharges. 

ASCARIS LUMBRICOIDES 

Characteristics. — This is the common round-worm, has a pale red color, 
is cylindrical in shape and has pointed extremities, resembling the ordinary 
fishing worm. The male is about 20 cm. long and 4 mm. thick and its tail 
is curled up over its abdomen. The female is larger, being about 30 cm. 
long and 5 mm. thick. The female produces millions of eggs which are 
disseminated in great profusion through the fecal contents of the intestinal 
canal. The eggs measure from .05 to .06 mm. in length and are both 
round and oval in shape. The embryos develop only from the round eggs; 
the oval form is unfruitful. The outer layer of these eggs has a rough 
nodular surface and is yellowish-brown in color. The life cycle of the 
round-worm does not require an intermediate host. The eggs propagate 
rapidly in moist earth, so that the surroundings of the patient may be 
readily contaminated from the intestinal discharges. This leads to the 
spread of this disease among the uncleanly, among whom this condition is 
most frequently found. More than one worm is commonly present and 
they may exist in great numbers, so great, in fact, that they may entwine 



216 



INTESTINAL PARASITES 



themselves in masses of sufficient size to produce intestinal obstruction. 

They may migrate to all portions of the gastrointestinal canal, appearing 
in the stomach and producing gastric irritation and 
vomiting; occasionally finding their way into the larynx, 
trachea and bronchi, producing there serious symp- 
toms of obstruction. They may enter the bile duct, 
causing jaundice and even abscess of the liver, and by 
penetrating into the appendix may produce appendi- 
citis. 

Symptomatology. — In the great majority of in- 
stances constitutional symptoms are absent. But there 
may be more or less intestinal irritation, which in 
young and delicate children is marked by digestive 
disturbances and mild nervous symptoms, largely reflex 
in their nature. The appetite may be lost or perverted, 
slight nausea and diarrhea may occur, and the child 
may be restless, irritable, sleepless and complain of 
headache. Picking at the nose and rectal irritation are 
common, but not at all characteristic, symptoms. In 
rare instances more severe nerv- 
ous symptoms, such as convul- 
sions, may occur. The writer ob- 
served one such instance in an 
apparently normal child, eight 
years of age, who lay in convul- 

Fig.34.— AscarisLum- s i ons f or eight or ten hours, and 

bricoides, Female, . . 

Head and Male, was immediately relieved and at 
once convalescent on the passage 
of a large ball of tightly matted round-worms. The convulsions in such 
cases may in part be the result of the intestinal obstruction and resulting 
intoxication which the ball of worms produces, or they may be caused, as 
the French writers believe, from the poisons which the round-worm ex- 
cretes into the intestinal canal. Eosinophilia may be associated with the 
presence of these worms. 

Diagnosis. — The above symptom group varies so greatly in different cases 
and marked symptoms are so commonly absent, that the diagnosis of 
round-worms is ordinarily made by seeing the worms in the intestinal dis- 
charges. When this disease exists, a cathartic, such as castor oil, will al- 
most certainly reveal the presence of the worms in the stools, but a much 
more accurate method of diagnosis is to examine the feces under the micro- 
scope. The eggs will always be «found in abundance. This latter method 
of examination is so reliable that it is advisable, following the treatment 
for this condition, to make a second microscopical examination of the 
feces to determine whether the eggs have entirely disappeared. 

Treatment. — Santonin is a specific for this condition. It is advisable 
to either combine it or follow it with calomel, and some hours later by a 





Fig. 35. — Egg of As- 
caris llimbricoides. 
(Wood.) 



OXYUKIS VERMICULAEIS 21 






saline laxative or by castor oil. Two doses of the santonin and calomel 
should be given, the first dose on an empty stomach before breakfast, and 
the second at bed-time, to be followed the next morning by the castor oil. 
The dose of santonin is one-half grain for a child one year of age and 
one grain for a five-year-old child. Larger doses may produce poisoning. 
This treatment may be repeated after an interval of one week, and in the 
great majority of instances a cure is effected. The following prescription 
offers a suitable form for the administration of this drug : 

J£ Santonin g rs# i 

Calomel grs. f 

Sacchari albi grs. vi 

M. Div. in chart No. 2. 

Sig. One before breakfast and one after supper for a child one year of age. 

All of the ingredients of this prescription may be doubled for a child 
five years of age. 

Trichuris Trichiura. — Trichuris trichiura, or the whip-worm, is a 
common intestinal parasite. It is a whip-shaped round worm, about two 
inches in length, which has its habitat in the large intestine. It is of 
little clinical or pathological importance, since it rarely produces either 
constitutional or local symptoms. 

OXYURIS VERMICULARIS 

Characteristics. — Oxyuris vermicularis is the ordinary thread-worm. It 
is not, like the round-worm, so largely confined to the uncleanly, but may 
occur among all classes of society. It is very small and looks not unlike 
a piece of white thread; is spindle-shaped and white in color. The male 
is between 3 and 4 mm. long, and the tail is curved toward the abdominal 
surface. The female is much larger, 9 or 10 mm. in length and two or 
three times as thick as the male, but its tail is not curved forward. The 
female produces thousands of eggs, oval in shape and about .05 mm. long. 
The eggs, however, of this species are not so important from a diagnostic 
standpoint as they are in the round-worm. The thread-worm requires 
no intermediate host. The child may reinfect itself or spread the disease 
among other children after contaminating its fingers by scratching the 
anus. The female lives in the large intestine, and the embryos make their 
way into the small intestine where the males predominate, but as they 
mature both males and females migrate to the large intestine. As the eggs 
and worms are discharged with the feces the surroundings of the child 
are contaminated. This offers a favorable opportunity not only for the 
reinfection of the child, but for the spread of the disease to other children. 
Symptomatology. — The irritation which these worms produce in the 
colon may result in mucous discharges. Pruritus ani is the most common 
and the most troublesome symptom. The intense itching of the rectum, 
which is much worse at night, is due to the fact that the worms migrate at 



218 



INTESTINAL PAKASITES 



this time to the outer rectal folds and they may there be seen by pressing 
apart the folds of the anus. This itching of the rectum causes the child 
to be sleepless and irritable, and results in scratching and tearing 
the part with the fingers; this is usually done during sleep. The 
traumas resulting from scratching very commonly produce eczema 
and scars about the anus. Thread-worms may be the reflex excit- 
ing cause of nocturnal incontinence of urine, pseudo-masturbation, 
and night terrors. Loss of weight, anemia and headache may 
occur. The most serious localized disturbance 
which can be produced by these worms in the large 
intestine is appendicitis, but this is a rare occur- 
rence. 

Diagnosis. — The symptom group above outlined 
at least suggests the presence of the thread-worm, 
and the diagnosis is confirmed by making an ex- 
amination of the anus. For reasons above given 
this is more successful if the inspection is made 

!/fM$l iff! some hours after the child has gone to bed. If the 
% \mi 1 I worms are n °t found in the rectal folds an enema 

% 111 -I'f should be given, and in the resulting discharge the 

worms can be seen. A dose of castor oil will also 
answer the purpose of bringing these parasites to 
light. 

Treatment. —The most effective remedy is flush- 
ing the colon with normal salt solution. High in- 
jections that completely irrigate and wash the mu- 
cus out of this organ are necessary to successful 
treatment. These irrigations should be followed by 
Fig. 36.— Oxyioris Vermi- 6 to 10 ounces f i n f us ion of quassia, injected 
cularis, Female, Imma- ,.,.,,, , ,,. i 1;1 i , n 

ture Female and Male, high into the colon ; this should be repeated every 

day for four or five days, and after a period of four 
or five days' rest the irrigation may again be resorted to. It may be neces- 
sary in obstinate cases to repeat this treatment as many as four or five 
times, but the great majority of cases are cured after the second or third 
course of injections. Each time before beginning the irrigation it is ad- 
visable to give a preliminary dose of calomel and santonin, of each one- 
half grain, followed by castor oil or some other cathartic. This treatment 
serves the purpose of driving these parasites out of the small intestine 
where they can be reached by the colon irrigation. 

In rare instances one comes in contact with a case of thread-worms 
that fails to respond to treatment. Some of these cases may be due to a 
lack of prophylactic treatment in connection with the cure above given. 
The ova are so commonly found under the finger nails as a result of scratch- 
ing, that in every case the greatest cleanliness should be observed. The 
child's hands and finger nails should be kept clean with soap and water, 
and in obstinate cases the child should sleep with closed pajamas so as 



ETIOLOGY 219 

to keep the fingers from coming in contact with the rectum during sleep. 
Fecal discharges should be disposed of with the same care and in the same 
manner as just described under the treatment for Ascaris Lumbricoides. 



CHAPTER XXV 
INTESTINAL INTUSSUSCEPTION 

Intestinal intussusception is the invagination of one part of the intes- 
tine by another; the upper portion of the gut commonly slips into the 
lower, but the reverse of this may take place, the lower portion slipping 
into the upper. This produces a cylindrical tumor composed of three 
parallel layers of intestine. This tumor may itself again be invaginated or 
swallowed up by the neighboring intestine; this double invagination is 
much more likely to occur where the small intestine alone is involved in 
the process. In intestinal invagination the mesentery is also swallowed 
up and drags at the head of the invaginated gut ; this greatly increases the 
traumatism and causes inflammatory processes in the affected part; it also 
aids materially in producing the more or less complete obstruction of the 
bowels, since the dragging of the invaginated mesentery pulls the invagi- 
nated gut out of line with the intestinal canal. 

Intussusception may occur throughout the intestinal canal, but in the 
vast majority of instances it involves some portion of the ileum or colon 
or both, and the different varieties depend upon the portion of the intes- 
tine involved. The ileocecal type is the most common; it includes 70 or 
80 per cent, of all cases; in this form the colon swallows up the cecum 
and ileum; the ileocecal valve preceding the mass may reach the rectum. 
The ileocolic type embraces from 10 to 15 per cent, of the cases; in this 
form the ileum slips through the ileocecal valve, the valve remaining in 
position. The colic type embraces 2 or 3 per cent, of the cases; in this 
condition the colon slips into itself, and passes downward toward the 
rectum. The ileac type embraces from 5 to 8 per cent. ; in this condition 
the small intestine is telescoped into itself and this commonly occurs in the 
ileum. 

Etiology. — Age is an important predisposing factor, as intussusception 
occurs in children very much more commonly than it does in adults. It 
is observed most frequently in the second half of the first year and dimin- 
ishes thereafter, but is not uncommon up to the sixth or seventh year. 
It is by far the most common form of intestinal obstruction observed in 
childhood. It occurs more frequently in weak, malnourished children, and 
especially in those that have suffered from previous intestinal disease; in 
these children the musculature of the intestine is weak, irritable and sub- 
ject to abnormal, irregular, peristaltic contractions, which are the great 
exciting causes of this disease. These abnormalities in peristalsis may be 
excited by constipation, intestinal disorders, improper food, injury to the 



220 INTESTINAL INTUSSUSCEPTION 

abdomen and irritations and inflammations of Meckel's diverticulum and 
the appendix. 

Pathology. — As previously noted, the swallowing of both mesentery and 
intestine increases the engorgement, aggravates the strangulation and pro- 
duces complete intestinal obstruction which results in necrosis and gangrene 
of the invaginated gut. Snow, of Buffalo, reported a case in an infant 
seven months of age, who for sixteen days had had symptoms of intussuscep- 
tion; six inches of gangrenous intestine which protruded from the rectum 
was removed and the infant recovered. In the chronic cases the obstruc- 
tion is not complete, but the invaginated intestine is held firmly in posi- 
tion by inflammatory tissues. 

Symptomatology. — General Symptoms. — This disease begins suddenly, 
not uncommonly during sleep, with severe intestinal pain which recurs in 
paroxysms. The pain is associated with vomiting, usually severe and per- 
sistent in character, and, after a few hours, with the passage from the 
bowels of bloody mucus and very little or no fecal matter. This symptom 
group is practically characteristic of the disease, and of great importance 
is the fact that these symptoms are associated in the beginning with little 
or no fever. 

The pain is similar to that which occurs in severe intestinal colic, the 
infant cries loudly, draws its legs upon its abdomen and squirms with pain ; 
after a time the paroxysm disappears, only to return with the same severity 
after a longer or shorter interval. The attacks of pain are supposed to be 
associated with violent peristalsis and perhaps to mark the various steps 
in the progress of the invagination. After a few hours they become less 
severe and from this time on the intestinal colic is no longer a prominent 
symptom of the disease. 

Vomiting occurs early and very frequently continues throughout the 
course of the disease. The intervals between the paroxysms may be meas- 
ured by minutes or by hours. The vomited matter consists first of food, 
then of mucus, perhaps stained with blood, then bile, and in some instances 
fecal matter; this is more marked in older children and is associated 
with complete intestinal obstruction. In a small percentage of the cases 
vomiting is not so prominent a symptom; it may come on late and recur 
only once or twice in twenty-four hours. 

Intestinal Discharges. — The bloody mucus which is discharged in 80 
per cent, of the cases, and commonly within the first twenty-four hours, is 
our most valuable symptom in the diagnosis of this disease. Gibson re- 
gards it when taken in connection with the other symptoms as pathogno- 
monic. The blood in rare instances is discharged in large quantities; it 
usually, however, occurs in such small quantities as only to slightly tinge 
the mucous discharges. These discharges of bloody mucus may be associated 
with tenesmus and relaxation of the rectal sphincter when the intussuscep- 
tion approaches the rectum. With the onset of this condition the first 
intestinal discharge may be normal, followed by slightly loose movements, 
which within the first twenty-four hours consist almost entirely of bloody 






DIAGNOSIS 221 

mucus, with little or no fecal matter. With the increase in the obstruc- 
tion, which commonly becomes complete, the discharge of gas and fecal 
matter ceases. In some instances, however, small quantities of fecal mat- 
ter and gas may escape through the invaginated intestine for several days. 
In the rare cases of chronic intestinal obstruction occurring in older chil- 
dren, gas and fecal matter continue to be discharged throughout the dis- 
ease. When gangrene occurs the discharges may contain shreds of putrid, 
foul-smelling tissue. 

Fever. — In the beginning intestinal intussusception is an afebrile con- 
dition. After the second or third day there may be a slight rise in temper- 
ature and if the child lives for four or five days the temperature rises as 
a result either of intestinal infection or of peritonitis. 

Physical Examination. — A tumor, which can be found in from 40 
to 50 per cent, of these cases, should be carefully searched for; abdominal 
palpation, however, should be made when the child is free from pain and 
the abdomen completely relaxed; anesthesia may be necessary in some 
cases ; the tumor, which is an elongated tender mass, is commonly found in 
the transverse or descending colon. The presence of localized tenderness 
may assist in the localization of the tumor. The examination per rectum 
with the finger, in 30 to 40 per cent, of the cases, will reveal the invaginated 
intestine which has pushed down almost or quite into the rectum and the 
examining finger on withdrawal may be covered with bloody mucus. This 
examination should be made in every instance, since the tumor after all 
is the only pathognomonic sign of this disease. The general appearance of 
the child is of value in the diagnosis ; in severe cases there is marked pros- 
tration, and the infant has a pale, anxious expression, which during an 
attack of pain may be associated with cyanosis and with a rapid feeble 
pulse. 

Course. — The course of this disease may be very acute, the child 
dying within the first twenty-four hours; these rapidly fatal cases, how- 
ever, are very rare. In most instances it lasts from a week to ten days; 
it reaches the crisis more rapidly in infants than it does in older children. 
When the case becomes chronic it may be prolonged indefinitely. 

Prognosis. — This depends largely upon an early diagnosis and early 
surgical interference; it is much more favorable in infants than in older 
children ; if the diagnosis is made in the first twenty-four hours more than 
60 per cent, recover. The average mortality according to Gibson is 53 
per cent. 

Diagnosis. — This is made by the sudden onset of a severe intestinal 
colic, associated with vomiting and with the passage of bloody mucus, but 
with the discharge of little or no fecal matter. This symptom group oc- 
curring as an afebrile condition is sufficient to warrant an exploratory 
laparotomy, even if the physical examination fails to reveal a tumor. The 
demonstration of the tumor, however, either by abdominal palpation or 
rectal examination, makes the diagnosis certain. This disease should not 
be confounded with enterocolitis, which is from the onset a distinctly 



222 APPENDICITIS 

febrile disease presenting an entirely different symptom group. It resembles 
this disease only in the passage per rectum of bloody mucus. Acute appen- 
dicitis may, by its vomiting, pain and obstinate constipation, suggest in- 
tussusception. In this condition, however, the bloody stools and tumor 
are absent, and the disease is distinctly febrile from its onset. The further 
points in the differential diagnosis of this condition may be made out by 
a study of the symptoms of appendicitis. 

The diagnosis of intussusception from other forms of intestinal ob- 
struction is, as a rule, not difficult, and in this differentiation practically 
only two conditions have to be considered, viz., obstruction from fecal impac- 
tion and from inflammatory bands caused by appendicitis or peritonitis. 
The diagnosis of fecal impaction may be made out by rectal examination 
and by physical examination of the abdomen, as well as by the history of the 
case and the results of the preliminary salt-water enema. Obstruction 
from inflammatory bands may be determined by the complete occlusion 
(no feces or gas), the severity of the vomiting, the absence of bloody 
mucous discharges, and the presence of appendicitis or peritonitis. 

Treatment.— No time should be lost in obtaining surgical relief, as 
there is little to be hoped for from any other line of treatment, and much 
to be lost by postponing surgical treatment in the hope that less radical 
measures will relieve the condition. All writers agree, however, that no 
harm can come from the introduction into the colon of large quantities 
(1 quart) of warm normal salt solution. In giving this enema the child's 
hips should be elevated and a rectal tube inserted into the sigmoid flexure, 
and through this tube, from the bag which is elevated not more than two 
feet above the patient, the water is allowed to flow. In some instances 
relief has followed. The forcible introduction of water, oil, air or gas, 
for the purpose of reducing the intussusception, is accompanied by more 
or less danger ; rupture of the intestine has occurred during these manipu- 
lations. 

By an exploratory laparotomy the surgeon may determine the char- 
acter of the operation to be made. It may be found that a simple reduc- 
tion of the intussusception is all that is necessary, or it may be necessary 
to shorten the mesentery at the site of the intussusception to prevent its 
recurrence, and in other instances a resection of the gut may be obliga- 
tory. All forms of intestinal obstruction, except that produced by fecal 
impaction, are essentially surgical. 



CHAPTEE XXVI 
APPENDICITIS 

The term appendicitis, as now used, includes periappendicitis, typhlitis, 
perityphlitis and localized abscess and peritonitis occurring in the appen- 
dicular region. 



PATHOLOGY 223 

Etiology. — The disease is rare in infancy, but after the second year of 
life becomes much more frequent and during childhood is not uncommon. 
Heredity, as Forchheimer has shown, is an important etiological factor. 
The hereditary predisposition may depend upon inherited anatomical pe- 
culiarities of the appendix, such as its length, location and patulency, or 
upon the character of lymphoid tissue associated with it, or on an heredi- 
tary tendency to constipation; at any rate it is a fact that this condition 
may be a "family" disease running through various generations. Among 
the exciting causes are constipation, especially fecal impactions in the ce- 
cum ; colitis involving the cecum and extending to the appendix ; intes- 
tinal infections which destroy the normal intestinal flora and substitute 
therefor pathogenic flora, such as the bacillus coli, streptococci and staphy- 
lococci; foreign materials such as fecal concretions; seeds and undigested 
food; intestinal worms; blows upon the abdomen, or unusual muscular 
exertion lighting up a latent inflammatory condition ; and lastly, scarlatina, 
typhoid fever, tonsillitis and intestinal grippe. These last-named infections 
may be associated with cases of appendicitis. Of these exciting causes 
bacteria are undoubtedly of the greatest importance. 

Pathology. — The appendix in the child is commonly located lower down 
in the pelvis than it is in the adult. This position of the appendix and 
cecum is of importance, in that in the physical examination of these parts 
the enlarged appendix, or tumor masses resulting from appendicitis, must 
be felt for lower down and often under the anterior spine of the ilium. 
This position of the appendix, often in the little pelvis, may direct the 
burrowing abscess deep down into the floor of the pelvis and up on the 
other side in close association with the rectum. The location of the ap- 
pendix, however, in the child is even more variable than it is in the 
adult; it not infrequently is directed upward and lies back of the cecum. 
The variability in the location of the appendix determines the various 
locations of the abscess and inflammatory thickenings which occur in this 
condition. 

The forms of appendicitis in children are similar to those occurring 
in the adult: the catarrhal, the ulcerative and the gangrenous. There is, 
however, on the part of the child an apparent predisposition to the ulcer- 
ative or perforative variety, since these cases occur in relatively larger pro- 
portion. In the catarrhal form the mucous membrane of the appendix is 
congested, inflamed, and its lumen distended with mucus or mucopus. In 
these cases the contents of the appendix are discharged into the cecum 
and there produce more or less irritation, aggravating an old colitis, which 
may have been the original cause of the appendicitis. At any rate colon 
infection and attacks of subacute colitis occur in these cases, and the per- 
sistent factor in many a chronic case of chronic colitis is an existing catar- 
rhal appendicitis. In the ulcerating or perforating form, the mucous mem- 
brane of the appendix becomes infiltrated and finally breaks down under 
the infection and distention. The perforation generally occurs near the end 
of the appendix, which not uncommonly holds a plug of hard fecal mat- 
16 



224: APPENDICITIS 

ter or a quantity of mucus and pus, which by their pressure have facilitated 
the rupture. In the gangrenous variety a portion of the distal end of the 
appendix becomes necrotic and sloughs off; this process, which is perhaps 
due to some disturbance of circulation, allows the contents of the appendix 
to be discharged through the opening produced by the slough. The fecal 
and other concretions present in both the ulcerative and gangrenous types 
may be an effect rather than a cause of the appendicitis. It is probable 
that most cases of appendicitis would remain catarrhal if there were a free 
opening through which the contents of the appendix could be discharged 
into the colon, but with the congestion of the mucous membrane this open- 
ing, at all times insufficient, becomes more tightly closed, shutting up 
within the small lumen of the appendix the mucus and pus formed by 
the inflammatory process. Various microorganisms, especially the colon 
bacillus, streptococci and staphylococci, play an important role in the etiol- 
ogy and pathology of the more severe cases. 

In the ulcerative and gangrenous forms of appendicitis the appendix is 
commonly walled off by an inflammatory exudation which catches and 
holds, at least temporarily, the infectious material discharged from the ap- 
pendix. This localized abscess thus formed may burrow into the pelvis 
as previously described, may make its way up behind the cecum or may 
even present itself anteriorly, perforating the skin; it more commonly, 
however, breaks through the inflammatory wall which surrounds it into 
the general peritoneal cavity, producing septic peritonitis. General peri- 
tonitis may immediately follow rupture of the appendix, when nature has 
not had time to wall off an inflammatory pocket for the reception of the 
infectious material; this occurs most commonly in the gangrenous forms. 
Inflammatory bands, which are thrown out during the acute process and 
commonly remain for some time after recovery from the attack, may catch 
and strangle loops of intestine, thus complicating the appendicitis with 
an acute intestinal obstruction. This is a danger to be watched for during 
the convalescence of operative cases, and is much more common in child- 
hood than in adult life. 

Symptomatology. — This disease may follow an indigestion, or be coin- 
cident with an intestinal infection. The initial symptoms are severe ab- 
dominal pain, colicky in character, recurring at intervals, commonly as- 
sociated with vomiting, which may or may not be repeated. Constipation, 
obstinate in character, is the rule; diarrhea may occur; fever is present. 
This symptom group occurs with such clearness as to at least suggest 
the possibility of appendicitis, which should lead to a careful physical 
examination, upon the results of which the diagnosis is ordinarily made. 

Physical Examination. — The child commonly assumes the recum- 
bent posture and lies with its legs Hexed upon the abdomen. By gentle 
palpation, localized tenderness may be located at McBurney's point, but, as 
a rule, it is lower down, on or below the level of the superior iliac spine. 
The amount of tenderness on pressure is to be estimated largely by watch- 
ing the child's face during examination; the facial expression is more 



SYMPTOMATOLOGY 225 

reliable than the child's answers in determining the question of localized 
tenderness. This examination also makes out the presence or absence of 
localized resistance of the muscles in the right iliac region; this localized 
muscular tension is of the very greatest value in the diagnosis, when 
present in association with the symptom group above given it indicates 
a rather active appendicitis; this is especially true in young children. A 
tumor or thickening of the tissues around the appendix, or the enlarged 
appendix itself, may be made out by careful bimanual examination. In 
making this manipulation the fingers of the left hand are pressed deeply 
into the back opposite McBurney's point, and the right hand in opposition 
to it is pressed gently down into the region of the appendix, carefully pal- 
pating the entire region, especially low down in the pelvis. In older chil- 
dren the introduction of the finger high up into the rectum may localize 
on the right an indurated mass. 

General Symptoms. — The pain and tenderness, however, which mark 
the onset of this disease commonly continue to be important symptoms, 
becoming rather less severe but more constant in character. The sudden 
cessation of pain, which is not infrequently associated with a fall in tem- 
perature, is an ominous symptom, especially when the pulse rate continues 
rapid and the child's general condition is not improved. This symptom 
group means rupture of the appendix with the relief of tension and the 
discharge of the infected material into the periappendicular region; this 
accident is so common that the symptom group which marks it must ever 
be kept in mind. 

Constipation, when very aggravated, is commonly associated with vom- 
iting, and this symptom group may suggest intestinal obstruction. The 
vomiting is more marked following rupture of the appendix and subse- 
quent involvement of the peritoneum. 

Fever. — A rise of temperature occurs early in this disease and its 
height may mark the severity of the process. This rule is not, however, 
without exception, as in rare instances cases of gangrenous and perfora- 
tive appendicitis may for the first few days run an almost afebrile course. 
Following the rupture of the appendix and periappendicular infection, 
there is a secondary rise in temperature which marks the progress of the 
sepsis or peritoneal inflammation. 

Blood Examinations. — The leukocyte count is of very great value 
not only in confirming the diagnosis of appendicitis, but also in helping to 
determine whether the disease is progressing favorably or unfavorably. In 
interpreting these blood counts, however, it should be remembered that in 
very young children the proportion of lymphocytes is much greater than 
it is in older children. There is in appendicitis, except in the very worst 
cases where resistance to the infection is almost lost, a marked leukocyto- 
sis of 12,000 to 30,000. This increase in the number of leukocytes is 
commonly in proportion to the activity of the process; in mild cases the 
leukocyte count may be 12,000 ; in septic cases during the acute stage it 
may run to 30,000. A high leukocyte count is commonly an indication 



226 APPENDICITIS 

of pus. Daily blood examinations should be made in all cases where the 
diagnosis is doubtful, or where an operation for any reason is postponed; 
an increasing leukocyte count is an unfavorable sign and indicates progress 
in the inflammation; a falling leukocyte count with other symptoms favor- 
able is a good sign, and is an indication that the child will recover from 
the present attack. A low leukocyte count occurs in fatal cases toward the 
end of the disease, but the low leukocyte count is here associated with 
septic temperature, profound prostration, a rapid, irregular and increasing 
pulse rate, and is an indication that the vital powers of the child are no 
longer able to call forth an army of leukocytes with which to fight the 
infection. A differential leukocyte count is also of value in determining 
the character of the process. When the polynuclear leukocytes are pres- 
ent in a percentage greater than 80, pus is probably present and this 
probability is greatly strengthened if the general leukocyte count is above 
14,000. 

Course. — The course of this disease depends largely upon the severity 
and character of the inflammation affecting the appendix. In the catarrhal 
form the symptoms previously noted may be mild in their onset and the 
disease may run its course within a week or ten days, terminating in re- 
covery. In the ulcerative form the onset is commonly much more severe, 
the pain, fever, vomiting and localized tenderness being very marked and 
increasing in severity, until, perhaps between the third and fifth day, per- 
foration occurs, producing a cessation of pain, fall in temperature and oth- 
erwise modifying the symptom group as previously noted. The subsequent 
history of these cases depends upon whether a general septicopyemia or a 
general peritonitis follows the rupture, or whether the infectious material 
is walled off from the peritoneal cavity by an inflammatory exudate. In the 
former case the child quickly succumbs unless perchance it be saved by a 
surgical operation. In the latter the localized abscess may after a number 
of days begin to show evidences of resolution and a slow convalescence fol- 
lows, or it may burrow or break into the surrounding tissues and place the 
child's life in immediate jeopardy. In the gangrenous 'form the initial 
symptoms are even more violent than in the ordinary perforative form; 
necrosis and general infection may occur on the second or third day of 
the disease. 

Diagnosis. — This disease may be differentiated from intestinal obstruc- 
tion by the presence of fever, the less severe pain, the absence of persistent 
vomiting and by the presence of the local symptoms of appendicitis made 
out by physical examination, and by the absence of bloody mucus from the 
intestinal discharges. Lobar pneumonia of the right lower lobe often 
presents a picture closely resembling appendicitis; in this condition there 
may be abdominal distention and pain and tenderness in the region of 
the appendix, but. the absence of the other physical signs of appendicitis, 
with the presence of the physical signs of pneumonia, should be sufficient 
to prevent this mistake in diagnosis, provided the physician has in mind 
the fact that such a symptom complex may be produced by pneumonia. 



TREATMENT 227 

Typhoid fever may be differentiated by the character of the fever, the 
presence of the Widal reaction and by the absence of the intestinal colic. 

Tuberculosis of the lymphatic tissues of the appendix may produce 
tumor masses in this region, which should not be mistaken for appendicitis. 
The history and course of the process which produced the appendicular 
tumor in tuberculosis is very different from the course of acute appen- 
dicitis. 

Prognosis. — The prognosis in private cases which are seen early and 
which have the benefit of surgical interference at the proper time is good ; 
more than 95 per cent, of these cases recover. The results that are ob- 
tained from surgical interference in the suppurative and gangrenous cases 
in children are much better than they are in adults. The high death rate 
(14 per cent.) which occurs in hospital cases is due to the fact that they 
do not always have the benefit of surgical interference at the proper time. 

Treatment The medical treatment demands that they be kept abso- 
lutely quiet in bed, with a total abstinence from food for two or three 
days, but water may be freely given. On the third or fourth day meat 
broths and small quantities of whiskey, well diluted, may be allowed. 
Cathartics or high rectal injections for the purpose of moving the bowels 
are to be avoided during the early acute stage of this disease. A light ice- 
bag placed for the greater portion of the time over the appendicular region 
is a valuable remedy; if this produces discomfort hot applications may be 
substituted, especially in very young children. Opium may be necessary 
for the relief of pain, but its use in children is not followed by the same 
good results seen in adults. When the pain of this disease is severe 
enough to demand opium it is better practice to refer the case to the 
surgeon. On the fourth or fifth day, with the subsidence of the symptoms, 
an enema followed by a dose of castor oil may be given, and thereafter 
the child may be allowed meat broth, beef juice, albumin water, and later 
milk. It should be kept quietly in bed until convalescence is assured; re- 
lapses during this period are especially dangerous. Following an attack 
the child should be carefully fed within the limits of its digestive capacity, 
violent exercise should not be allowed for some months, constipation 
should be carefully avoided. These precautions are necessary to prevent a 
second attack. 

In the milder or catarrhal forms of appendicitis it is the duty of the 
physician to try to carry the child through the attack and refer it to the 
surgeon for an interval operation; this is much better practice than oper- 
ating upon every case as soon as a diagnosis is made. Under medical treat- 
ment 95 per cent, of these cases recover from the first attack, and tins 
mortality would not be diminished by operative interference during the 
attack. The treatment of the appendicular attack in the great majority 
of cases is purely medical and in the handling of this phase of the treat- 
ment the physician has perhaps more experience than the surgeon. During 
the treatment of any case of appendicitis, however mild, the physician must 
realize that at any time the case may become a surgical one demanding im- 



228 PERITONITIS AND ASCITES 

mediate operative measures. For this reason the danger signals above 
outlined must be carefully kept in mind. In the more severe types of 
appendicitis, when the initial symptoms indicate that one is in the pres- 
ence of a suppurative or gangrenous appendicitis, the child should, in the 
midst of the attack, be referred to the surgeon ; no possible good can come 
from delaying surgical interference in these cases, and a difference of 
twenty-four or thirty-six hours may materially diminish the child's chances 
for recovery. Every well-defined case of appendicitis should sooner or 
later come into the hands of the surgeon. The only valid reason for post- 
poning indefinitely surgical interference is that there may have been a 
mistake in diagnosis; in such cases one should await the subsequent his- 
tory of the child to confirm or deny the diagnosis. 



CHAPTER XXVII 
PEKITONITIS AND ASCITES 

PERITONITIS 

Etiology. — Appendicitis is the most common cause of acute peritonitis, 
and tuberculosis is the only cause of chronic peritonitis in childhood. 
Acute peritonitis from other causes, though comparatively infrequent, is 
met with often enough to deserve careful consideration. 

The microorganisms most commonly associated with acute peritonitis 
are the bacterium coli, the streptococcus pyogenes and pyocyaneus, the 
staphylococcus aureus, the pneumococcus, the gonococcus, the diplococcus 
intestinalis, and with the chronic form of this disease the tubercle bacillus, 
assisted in its destructive process by streptococci, staphylococci, and other 
organisms. These various microorganisms are associated with more or less 
distinct types of this disease. The bacterium coli communis occurs espe- 
cially in the forms of acute peritonitis which have developed after intes- 
tinal perforation. Streptococci and staphylococci occur in the perfor- 
ative form and in the septic types of this disease, and also in the forms of 
peritonitis that follow the infective fevers, such as erysipelas, acute tonsil- 
litis, diphtheria, influenza, scarlet fever, and measles. Pneumococcus peri- 
tonitis may occur as one of the localizations of a general pneumococcus in- 
fection, or it may spread from a pneumococcus inflammation of the lungs 
and pleura. Gonococcus peritonitis is also almost always secondary to 
gonococcus vaginitis. The gonococci entering through the uterus and fal- 
lopian tubes, or in any manner finding their way into the pelvic tissues, 
start up there a local inflammation of the pelvic peritoneum, which may or 
may not become a general peritonitis. 

Exciting Causes. — Appendicitis is the most important cause of acute 
peritonitis and its exciting causes become, therefore, the common exciting 
causes of peritonitis. Very rarely typhoid fever, tuberculosis, and dysen- 



PERITONITIS 229 

tery may cause perforation and produce peritonitis. A perforating nicer of 
the stomach and duodenum is one of the rarest causes. Suppurative pro- 
cesses in the liver and gall-bladder, strangulated hernia, intestinal obstruc- 
tion, blows upon the abdomen, perforating wounds from gunshot injuries 
or sharp instruments, and operative measures in the peritoneal cavity may 
produce peritonitis. The acute infectious diseases previously mentioned, 
however, are responsible for a majority of the cases that cannot be traced 
directly to appendicitis or tuberculosis. In the peritonitis which occurs in 
the newly born infant the infection is either a septic one entering through 
the umbilicus or it is due to an enterocolitis which furnishes a favorable 
opportunity for the infection of mesenteric lymph nodes and later of the 
peritoneum. 

Pathology. — The pathological process varies largely with the character 
of the inflammation. In all cases this membrane is more or less congested 
and covered with a serous or fibrinous exudate. In the fibrinous cases the 
coils of the intestine and the omentum are frequently bound together with 
a fibrinous exudate which greatly interferes with peristalsis. In some cases 
there is a serous exudation into the peritoneal cavity, but this is usually not 
marked except in the chronic tuberculous form. Pus is found especially in 
the perforative cases and those due to pneumococcic infection. The pus in 
the perforative cases has a foul fecal odor, is usually encapsulated about 
the appendix or site of perforation, but it may be, in the rapidly fatal cases, 
widely distributed throughout the general peritoneal cavity. The pus in the 
rare cases of pneumococcic peritonitis is very abundant, has no fecal odor, 
and is usually walled off and held by a single large inflammatory sac, which 
has a tendency to point toward the umbilicus; spontaneous perforations at 
this point may discharge the pus sac and result in recovery. 

Symptomatology. — The symptomatology of peritonitis occurring during 
the first days or weeks of life is very insidious. The symptoms of sepsis 
or of intestinal irritation may be present and almost entirely mask the 
inflammatory process going on in the peritoneum. Then perhaps abdom- 
inal distention and tumefaction lead to a more careful physical examination 
of the abdomen, which may be hard, tense, and give the peculiar resist- 
ance on palpation which is more or less characteristic of inflammation of 
the peritoneum. In this way a diagnosis may be made before the death 
of the infant, as this is always a fatal disease. In many cases, however, 
the diagnosis is made on the post-mortem table. Peritonitis occurring in 
later infancy and childhood is a more open and frank disease and not 
necessarily a fatal one. Its onset depends largely upon the causative fac- 
tors. In appendicitis a general peritonitis is announced by the sudden ces- 
sation of pain, fall in the temperature, increased rapidity of the pulse, and 
great prostration of the patient; these symptoms are followed, when re- 
action occurs, by a rise in temperature and by the appearance of the local 
signs of peritonitis. If the condition be due to a pneumococcus infection 
of the peritoneum the symptoms are sudden in their onset and general in 
character, with fever, chill, headache, and all the evidences of a general 



230 



PEKITONITIS AND ASCITES 



pneumococcic infection such as we have in pneumonia. When these symp- 
toms begin to subside, at the end of five or six days, abdominal pain, dis- 
tention, and tumefaction call unmistakable attention to the localized in- 
flammatory process in the peritoneum. In this form of the disease the 

bowels are loose and 
the abdomen becomes 
slowly distended with 
the fluctuating mass 
of pus, which may be 
outlined by palpation 
and percussion, and 
which usually occu- 
pies the lower middle 
portion of the abdo- 
men and points to the 
umbilicus. In some in- 
stances, however, the 
pus sac may be in one 
or the other iliac re- 
gions, though com- 
monly pointing to the 
umbilicus. The onset 
of gonococcus perito- 
nitis is insidious, oc- 
curring almost always 
in girls, since it is 
commonly preceded by a gonococcus vaginitis. The character of the in- 
flammation in these cases is for the most part mild, spreading slowly and 
involving, as a rule, only the pelvic or lower abdominal peritoneum. The 
diagnosis is made by the presence of vaginitis and by the localized pain and 
tumefaction in the lower abdomen and pelvis. These cases, however, as 
Koplik says, are not always benign, but may result in a general peritonitis 
ending in death. 

General Symptoms. — The pain in peritonitis is usually in the right 
iliac fossa or the umbilical region and from thence spreads, involving the 
whole abdomen. The patient lies on his back, with his legs flexed on his 
thighs, his abdomen distended with gas and tender to pressure. He 
breathes superficially and rapidly, so as not to bring into play the dia- 
phragm or abdominal muscles. He dreads being handled or touched; his 
facial expression is anxious and his whole attitude is that of protecting the 
abdominal region from injury; his general appearance is that of serious 
illness; the body may be hot and dry, the extremities cold and cyanotic. 
Fever is almost always present, but the height of the temperature bears no 
relationship to the seriousness of the disease. The pulse may range from 
120 to 130; it is small, weak, and increases in rapidity with the downward 
progress of the disease. Vomiting is commonly present and may be very 




Fig. 37. — Position in Acute Peritonitis. 



PEKITONITIS 231 

persistent; in the perforative cases its severity usually increases with the 
progressive involvement of the peritoneum. The vomited matter is at first 
food, then mucus, bile, and, in the more aggravated cases, a black coffee- 
ground material which may have a fecal odor. Constipation of an aggra- 
vated type is the rule, but diarrhea may occur, especially in those cases that 
follow the acute infections. With the progress of the disease the abdomen 
becomes more distended with gas, so that the liver dullness may be obliter- 
ated; general tumefaction of the whole abdominal wall becomes more and 
more marked, and in septic cases the fever and general symptoms are those 
of a septicopyemia. Leukocytosis is marked, especially in the septic cases. 

Physical Examination. — The diagnosis is made by the physical ex- 
amination. The tenderness may be localized or general. The abdominal 
resistance and induration, which are such all-important signs, may be either 
local or general, or may begin from a focus and spread gradually over the 
entire abdomen. By percussion or bimanual palpation one may localize the 
exudation. 

Prognosis.— In the new-born the disease is fatal; in older infants and 
children the prognosis depends largely upon the character of the inflam- 
matory process. In chronic, tuberculous peritonitis the prognosis is good. 
In gonococcus peritonitis a very large per cent, of the cases recover without 
operative interference. In pneumococcus peritonitis the prognosis is also 
commonly good if operative measures are resorted to at the proper time. 
In traumatic peritonitis, which is from its inception a purely surgical con- 
dition, the prognosis will depend largely upon the severity of the injury 
and early operative interference. In perforative peritonitis the prognosis 
has been previously discussed under Appendicitis. 

Treatment. — In the perforative forms of this disease, as previously 
noted under Appendicitis, the cases are essentially surgical, and as soon as 
a diagnosis is made operative interference should be resorted to. In the 
milder traumatic forms of peritonitis, however, and in those cases which are 
caused by acute infections, the medical treatment may be most important. 
The patient should be kept absolutely quiet and not be allowed to do any- 
thing for himself that can be done by others. Cold applications should be 
applied to the abdomen, especially in the early stages of the disease ; later, 
after four or five days, when the abdomen is tender to the touch, hot appli- 
cations may not only be grateful but may be of value in helping nature to 
dispose of the inflammatory exudate within. 

The dietetic treatment is most important. For the first two or three 
days absolute starvation is necessary, water only being allowed ; after this, 
good whiskey or brandy, well diluted, and beef or mutton broth may be 
given; the subsequent dietetic treatment will depend upon the age of the 
child and the extent of the peritoneal inflammation, and should follow 
along the lines previously outlined under Chronic Indigestion. If after a 
few days the peritonitis is clearly demonstrated to be of. such a character 
that perforation of the bowels is not to be feared, a saline cathartic, prefer- 
ably sulphate of magnesia or Eochelle salts, should be given. The thorough 



232 PERITONITIS AND ASCITES 

unloading of the bowels in the non-perforative cases is of the very 
greatest importance and materially assists in starting convalescence. In 
those cases, however, where appendicitis or typhoid fever either threatens 
or has produced perforation, cathartics are contraindicated. The use of 
opium may be necessary to relieve pain, but it should be used with great 
discretion, and when perforation has occurred it is contraindicated. The 
best preparation of opium is morphin and it should be given hypodermically, 
1-50 of a grain for a child one year of age and 1-20 of a grain for a child 
six years of age, to be repeated if necessary. Enemata for unloading the 
lower bowel should be employed in the cases where they are not contrain- 
dicated by disease of the large intestine, such as in appendicitis. Gono- 
coccus peritonitis is to be treated by trying to cure the causative vaginitis (a 
very difficult matter) and by general tonic treatment, including proper 
food, iron, cod-liver oil and fresh air, and by the local treatment above 
noted. Pneumococcus peritonitis is to be treated by general sustaining 
measures, such as are used in pneumonia, and later by operative measures 
for getting rid of the pus in the abdominal cavity. 



ASCITES 

Ascites, or the accumulation of serum in the peritoneal cavity, has its 
origin in children commonly in a tuberculous inflammation of the peri- 
toneum. It may also be caused by an atrophic cirrhosis of the liver, 
tumors, enlarged lymph nodes which obstruct the portal circulation, dis- 
eases of the heart, producing a failure in the general circulation, Bright's 
disease, and severe anemia. 

Differential Diagnosis. — Ascites from cardiac weakness is always asso- 
ciated with swelling of the legs and with unmistakable symptoms pointing 
to disease of either the cardiac valves or muscles. Ascites from Bright's 
disease is associated with a general anasarca and the urine findings of that 
disease. Ascites from grave forms of anemia is always associated with a 
cachexia, and a blood examination establishes the diagnosis. Ascites from 
local disturbances of the portal circulation may be confused with tubercu- 
lous peritonitis. Cirrhosis of the liver is rare in children and is com- 
monly of syphilitic origin. Other evidences of syphilis and the absence of 
the physical signs of peritonitis usually suffice to make the differentiation; 
if not, after the abdominal fluid has been removed by tapping, a contracted 
and nodular liver may be demonstrated, or, failing in this, the negative tu- 
berculin skin reactions may throw light on the subject. Tumors and en- 
larged lymph nodes (tuberculous) of sufficient size to produce ascites by 
obstructing the portal circulation can, as a rule, be demonstrated by palpa- 
tion after removal of the serum. In the presence of a marked ascites in 
children the physician should remember that tuberculosis is the common 
cause of this condition, and that often the abdominal cavity in this disease 
may be distended with serum without any very acute symptoms; there may 



MALFORMATIONS OF RECTUM AND ANUS 233 

be very little tenderness and induration of the abdominal wall and the 
condition may have developed very insidiously. For these reasons ascites 
due to a low grade of chronic tuberculosis is very commonly suspected to be 
due to other causes. The importance, therefore, of making a thorough 
examination for every sign or symptom of tuberculosis cannot be exagger- 
ated. 



CHAPTER XXVIII 

THE KECTUM AND ANUS 

MALFORMATIONS OF RECTUM AND ANUS 

Complete or partial congenital occlusion of the rectum or anus may 
occur. Atresia of the anus may result from the failure to absorb the skin 
covering, which normally guards the rectum during intrauterine life. This 
condition may usually be made out a few hours after birth by the bulging 
of the rectum beneath the skin, and a slight exploratory incision discovers 
the rectum and cures the deformity. Atresia of the rectum is a more seri- 




Fig. 38. — Malformations of the Rectum. 

ous matter; in this condition the occlusion of the rectum is commonly 
located two or three inches from the anus. In some instances the anal 
end of the rectum below the occlusion is patulous and continuous with a 
patulous anus; in such cases the exploring finger introduced through the 
anus into the rectum may readily reach the septum and direct the trochar 
which relieves the obstruction by puncturing this septum. In another 
group of cases there is congenital absence of the rectum below the point of 
occlusion. The blind sac of the rectum, some inches from the anus, is 
connected with it by an impervious cord, which represents the undeveloped 
rectum. In some of these cases the contents of the rectal pouch find their 
way by fistulous tracts through the peritoneum or into the bladder, vagina, 
or urethra. In those cases where occlusion is complete immediate sur- 
gical measures are necessary. In other cases, however, where the fistulous 
tracts are wide enough to serve the temporary purpose of emptying the 



234 THE RECTUM AND ANUS 

rectal pouch, a surgical operation may be postponed for a short time until 
the infant is stronger. 

POLYPUS OF THE RECTUM 

Polypus of the rectum is not infrequent in children; the tumor is at- 
tached by a pedicle to the rectal wall and is usually single, but occasionally 
more than one tumor is present. It may exist for a long time without 
presenting itself at the rectum and during this time there may be more or 
less rectal irritation, with tenesmus and blood and mucus in the stools. 
The diagnosis may be made by introducing the finger into the rectum; in 
this way the tumor may very readily be outlined and differentiated from 
hemorrhoids and intussusception. A rectal examination should be made in 
all cases in which there is an unexplained hemorrhage from the rectum. 

Treatment. — Eectal polypi may easily be removed by twisting the pedi- 
cle with forceps or with a wire snare. Following their removal, the rectal 
irritation rapidly subsides and the growth does not commonly recur. 

PROLAPSE OF THE RECTUM 

This condition is usually seen in children under six months of age; 
the almost straight rectum, with its weak attachments at this period of 
life, predisposes to prolapse. It occurs more commonly in malnourished 
children suffering from diarrhea and constipation. Eectal, vesicle, or 
genital irritation produced by thread-worms, fecal concretions, rectal polypi, 
vesicle calculi, cystitis, urethritis, and phimosis may be factors in pro- 
ducing it. In mild cases the mucous membrane of the anus may be but 
slightly everted when the bowels are moved and the blood and mucus may 
appear upon the napkin. In more severe cases the rectal wall may be 
prolapsed, forming a dark-red corrugated tumor two or three inches long, 
which bleeds readily on manipulation ; at the end of this tumor a depression 
marks the anal opening. The prolapsed rectum can, as a rule, easily be 
replaced by gentle pressure, the prolapse recurring again when the bowels 
are moved. In rare instances the tumor remains down and cannot be re- 
placed by simple manipulation; in such cases the parts may bleed, become 
much swollen and inflamed, and strangulation and ulceration of the mu- 
cosa may occur. 

Treatment. — The reduction of the tumor mass is commonly easily 
accomplished by manipulating it gently upward through a cold, moist 
towel; if difficulty is experienced in reducing the tumor the child should 
be placed in bed, stomach downward, and cold compresses applied to the 
part. Following these applications, the tumor may be easily reduced; if 
not, a few inhalations of chloroform will relieve the contracted muscles 
and make the reduction of the prolapsed rectum an easy matter. The 
rectum having been returned to its normal position, the object of all sub- 
sequent treatment is to keep it there. In order to accomplish this it is 



FISSUEE OF THE ANUS 235 

advisable to keep the child in bed, or at least in a reclining posture, until 
all local irritation of the rectal mucous membrane has been removed. Pin- 
worms and colitis, if they exist, are to receive prompt attention. If phi- 
mosis be present the infant is to be circumcised, as the reflex irritation 
from the genital organs may be an important factor in producing subse- 
quent attacks of prolapse. The rectum may be retained in position by 
strapping the buttocks with adhesive plaster when the child is on its feet 
and by having the child lie down before every movement of its bowels. 
Following the evacuation of the bowels, a large injection of cold, normal 
salt solution should be given; these cold injections are of great value in 
the treatment. In still more severe cases the thermo-cautery may be used 
on the prolapsed mucous membrane, making a number of linear cicatrices 
in a longitudinal direction. In rare instances amputation of the tumor 
may be necessary; this operation is usually attended with success. 

FISSURE OF THE ANUS 

This condition is not uncommon; it is produced by constipation; the 
passage of large, hard, fecal masses stretches and tears the mucous mem- 
brane about the anus. Infection may follow this injury and a small fissured 
ulcer may form, coated with pus and mucus and imbedded in the folds of 
the mucous membrane, which is more tightly grasped by the sphincter ani, 
because of the irritation produced by the fissure. Fischl says that fissures 
of the anus occur almost exclusively on the posterior rectal wall, and that 
they can be seen only by placing the child upon its back, with its pelvis 
elevated and legs widely separated and flexed on the trunk ; in this position, 
with fingers on either side of the anus, pressing it apart, the fissure is 
exposed. The condition may be complicated or even produced by the pres- 
ence of pin worms, the parts being torn by scratching. These ulcers are 
extremely painful when they are touched or when the rectum is manipulated 
in any way. Defecation is resisted by the child and, when it can no longer 
be postponed, causes great pain. The chronic constipation which is so com- 
monly the cause of this condition is still further aggravated by its presence, 
the powerfully contracted sphincter resisting the passage of fecal masses. 
There is little tendency to spontaneous recovery. So great is the pain 
produced by defecation in some of these cases that retention of urine occurs 
as a result of the child's dread of bringing into action the muscles of the 
bladder, which are so closely associated physiologically with the muscles of 
the rectum. 

Treatment. — The constipation should be relieved by laxative medicines, 
such as compound licorice powder for children and milk of magnesia for 
infants. In mild cases the fissure should be treated daily by carefully 
cleansing with a cotton-wrapped probe and then touching it with a 2-per 
cent, solution of cocain muriate, following this by the application of a 
10-per cent, solution of nitrate of silver. Under this treatment mild cases 
recover. The strength of the silver nitrate solution must be regulated by 



236 



THE EECTUM AND ANUS 



the pain and discomfort which follow its use. More severe cases are to be 
treated surgically; these usually get well following thorough dilatation 
and stretching of the sphincter under complete anesthesia. 

SPASM OF THE ANUS 

This condition is commonly due to fissure; it may occur in neurotic 
children from causes which produce irritation of the rectal mucous mem- 
brane; it produces constipation, tenesmus, and pain on defecation. For 
the relief of this condition mild laxatives are indicated; warm olive oil 
injected into the rectum may be of value. If these means fail, forcible 
dilatation of the sphincter muscle should be resorted to. 



PROCTITIS 

Proctitis, or inflammation of the rectum, may exist unassociated with 
catarrhal conditions of other portions of the intestinal mucous membrane. 
It may be produced by thread worms, by the frequent use of glycerin, soap, 
and other irritating suppositories, by the careless use of the thermometer, 
by rectal tubes used in giving enemata, or it may be a complication of 
vulvovaginitis. It is characterized by tenesmus, constipation, painful de- 
fecation, and a discharge of pus and blood associated with tenesmus. It 
may be relieved by mild cathartics and rectal injections of saline solutions 
or olive oil. Occasionally mild astringent solutions of one-half per cent, 
of nitrate of silver are indicated. 



SECTION V 

NUTRITIONAL DISORDERS 

CHAPTER XXIX 

RICKETS 
{Rachitis) 

Rickets is a chronic disease characterized by nutritional disorders, and 
consequent lack of development and perverted function on the part of 
nearly every organ and tissue of the body. It affects chiefly the bones, 
nervous system, muscles, mucous membranes, ligaments, and blood, and 
is believed to be largely a disturbance of calcium metabolism. 

Etiology. — Rickets is a disease of infancy; more than 80 per cent, of 
the cases occur under two years of age; it rarely begins during the first 
three months and is unusual after the third year. It is a very common 
and widespread disease; in our largest cities perhaps 90 per cent, of the 
infants of the poor show some signs of rickets. It is, however, much more 
common in cities than it is in the country, because a greater percentage of 
country children are breast-fed, live under better hygienic conditions, spend 
a greater portion of their time in the open air, and are altogether better 
fed. Heredity is an important factor. 

Rickets occurs more commonly in cold than in warm climates. This is 
due not so much to climate as it is to the conditions of life which cold 
climates force upon a poverty-stricken population. Impure air and lack of 
sunshine are very important causative factors which act largely through 
the unfavorable influence they exert on the child's digestive capacity. 

Faulty feeding is the most important cause of rickets. This disease 
rarely occurs in breast-fed babies, unless lactation is prolonged or the 
mother's milk, by reason of her vocation or ill health, furnishes insuffi- 
cient nutrition to the rapidly growing infant. It is, however, very com- 
mon among artificially fed infants who are insufficiently nourished on im- 
proper food formulas. A marked excess of carbohydrates and a notable 
deficiency in fat, protein and salts are the special dietetic errors most closely 
related to the etiology of rickets. This is the reason condensed milk, Nes- 
tle's food, malted milk, and other proprietary foods which do not require 
fresh milk in their preparation, are such potent factors in producing rickets. 

237 



238 



EICKETS 



It is a well-founded belief that a deficiency of fat in the infant's food is the 
most important of these dietetic errors and is most commonly related to 
the etiology of rickets. The absence of fat interferes with the proper 
assimilation of lime and phosphorus and this, perhaps, explains the potency 
of fat starvation as an etiological factor of this disease. The prevalence of 
rickets among the negroes and Italians of our large cities is not due to 
racial or hereditary influences, but is purely a question of bad hygiene and 
improper food. 

Pathology and Morbid Anatomy.— At the junction of epiphysis and 
diaphysis the ribs and long bones are enlarged by a proliferation of poorly 
constructed vascular cartilaginous and bony tissue between the epiphyseal 




Fig. 39. — Bony Deformities in Rickets. (A. Freiberg.) 



cartilage and the cancellous portion of the diaphysis. Bony structures 
everywhere, and especially the long bones, are niore vascular and cancellous 
than normal, and there is increased resorption of bone; the subperiosteal 
calcification and formation of new bony tissue is interfered with. Such 
bones contain only one-third instead of the two-thirds mineral matter which 
normal bones contain. These changes produce an increased flexibility of 
the bones which predisposes the infant to the deformities so characteristic 
of rickets. 

Muscular tissue is everywhere poorly formed, and the muscular fibers 
are infiltrated with fat and may show partial fatty degeneration. The 
muscles are poorly nourished, weak, flabby, easily stretched, and offer an 



SYMPTOMATOLOGY 



239 



insufficient support to the viscera and bones which they cover. The liga- 
ments are weak, flabby, easily stretched, and do not properly sustain the 
bony structures. 

The spleen is notably enlarged, it is anemic, its Malpighian bodies are 
atrophied and its function as a blood-forming organ is interfered with. 
The lymph nodes are slightly enlarged. The liver is somewhat increased 
in size and displaced downward. 

Symptomatology. — Eickets is a chronic malnutrition affecting every 
part of the body. The bony lesions are the most pronounced, the most 
characteristic, and the most easily recognized, but they are not the earliest 
nor are they the most important 
signs of this disease. A general 
failure of nutrition, manifested 
by the following symptom 
group, presents the syndrome 
upon which the diagnosis is 
made; retardation in physical 
development ; muscular weak- 
ness; inability to sit erect, to 
hold the head up, or to use the 
legs in a normal manner; 
flabby and undeveloped mus- 
cles; marked anemia; general 
nervous irritability; scarcity of 
hair on the back of the head 
due to restlessness and head 
sweating when asleep; tendency 
to fever from slight causes; 
late teething; a large, square, 
flat head with open fontanels; 
a chest contracted above and 
constricted transversely at the 
diaphragmatic attachment; flar- 
ing ribs below the diaphragm, 

turned upward upon a markedly distended abdomen; a rickety rosary of 
bead-like prominences at the junction of the ribs with the costal cartilages ; 
knob-like prominences of the bones just above the ankles and wrists ; con- 
stipation; a tendency to gastrointestinal disturbances and bronchial ca- 
tarrh; large belly; enlarged spleen and a liver protruding below the costal 
margin. In the more severe forms of rickets the above symptoms are much 
exaggerated and the deformities which result from diseased viscera, weak 
ligaments, ill-developed muscles, and flexible bones, are very great. 

General Appearance. — Eachitic babies in the early stages may be fat 

and flabby, so that to the prejudiced eye of the mother they may appear 

normal, while to the practiced eye of the physician they present at a glance 

the characteristic signs of rickets. As the disease advances, however, they 

17 




Fig. 40. — Rickets. 



240 RICKETS 

become emaciated and then the thin, old face, large, square head, resting 
on a narrow, contracted, deformed chest, the large, distended abdomen, the 
crooked back, the thin, bent, and deformed arms and legs present the char- 
acteristic picture of advanced rickets with which even the laity are familiar. 

General Symptoms. — Head sweating when the infant sleeps is one of 
the early significant symptoms and should lead to a search for other signs 
of rickets. Delayed and difficult dentition is an almost constant accom- 
paniment of even the mild forms of rickets. In a normal infant a tooth 
may come through with little or no constitutional disturbance, but in a 
rachitic child it commonly produces fever, sleeplessness, general nervous 
irritability, and some slight gastrointestinal disturbance. In fact, the 
severity of these symptoms, on the cutting of a tooth, may be an important 
indication not only of the presence of rickets, but of the severity of the 
nutritional disturbances which it has produced in the nervous system. The 
teeth of the rachitic infant are poorly formed and decay early. 

Nervous symptoms are of great value in the early diagnosis of rickets. 
Rachitic children are fretful and nervous, poor sleepers, toss restlessly in 
their sleep, and, as a result, very commonly have an occipital baldness. Re- 
flex and toxic agents have a highly exaggerated influence on their nervous 
systems; slight reflex and toxic factors in the intestine and elsewhere pro- 
duce high fever and convulsive symptoms. The predisposition of the 
rachitic infant to fever and convulsive disorders occurs early and may be 
an aid to an early diagnosis; convulsions or fever occurring in an infant 
from a trivial or from no apparent exciting cause should lead to a careful 
search for other signs of rickets. Laryngismus stridulus and tetany are 
nervous syndromes, very closely associated with the more advanced and 
severe types of rickets. Spasmophilia, or exaggerated peripheral nerve 
excitability, is one of the most characteristic phenomena seen in rachitic 
children. 

Gastrointestinal disorders occur very commonly and very early in most 
cases of rickets; in this disease there is a predisposition to catarrhal dis- 
eases which may be especially marked on the part of the gastrointestinal 
tract. In some instances the gastrointestinal disturbances precede the 
rickets and may be considered as causative factors. The pot-belly of rickets, 
which develops early, is an important symptom and is associated with fre- 
quent attacks of indigestion and intestinal fermentation; in this condition 
the abdominal muscles are relaxed, flabby, and greatly distended by the 
flatulent intestines. The enlarged spleen and the downward displacement 
of the liver can easily be made out by palpation and percussion. 

Hernias, both inguinal and umbilical, are very frequently seen in 
rachitic infants ; in fact, rickets is the most common predisposing cause of 
infantile hernias. The recti muscles are sometimes separated as much as 
an inch by abdominal distention. 

Weak ligaments and muscles are always present and are largely respon- 
sible for the helplessness or physical backwardness of the rachitic infant; 
the curvature of the spine and the tardiness of the infant in sitting, stand- 



SYMPTOMATOLOGY 



241 



ing, walking, and in making all the complicated muscular movements are 
largely due to this cause. 

Bony deformities are the most characteristic and easily recognized signs 
of rickets; some of these occur early in the disease. The beading of the 
ribs, or rickety rosary, the horizontal depression of the ribs at the dia- 
phragmatic attachment and their flaring upwards below this line, the 
marked enlargement of the long bones just above the wrist and ankle may 
be counted among the bony changes which are of great value in the early 
diagnosis of rickets. 
As the disease ad- 
vances the bony de- 
formities are more 
exaggerated ; the soft 
vertebrae, with their 
relaxed ligaments 
and weak muscular 
support, result in 
gradually increasing 
curvatures of the 
spine ; the posterior 
curvature (kyphosis) 
is the most charac- 
teristic and common- 
ly involves all the 
lower portion of the 
spine below the mid- 
dorsal region; exten- 
sive lateral curva- 
tures are also com- 
mon ; rotary curva- 
tures are also noted. 
Eachitic curvatures 
are not as sharp and 
angular as those due 
to tuberculous dis- 
ease and they are 

not, especially in their earlier stages, fixed; they will, as a rule, 
entirely disappear when proper pressure and extension is applied. The 
clavicle may be curved upward and forward in its inner third. In 
severe cases the pelvis is permanently deformed, small, and especially 
contracted in its anteroposterior diameter. The arms and legs may 
be greatly deformed by the curving and twisting of long bones; the hu- 
merus may be curved outward and the natural outward curve of the radius 
and ulna may be exaggerated. In the lower extremities the most common 
deformity is an outward curvature of the lower third of the tibia, producing 
"bow legs" ; we may also, much less frequently, have "knock-knees/' which 




Fig. 41. — Knock-knees and Bow-legs Due to Rickets in 
a Sister and Brother, Aged Five and Three. 



242 KICKETS 

Holt says "are more common in females and are believed to be due to an 
overgrowth, of the inner condyles of the femur." The cranium presents 
some of the most important characteristic bony deformities. The head is 
larger than normal and the anterior fontanel is much delayed in closing; 
at one year of age it may measure from iy 2 to 2y 2 inches in both diameters, 
while at this time it should not measure more than y 2 or 1 inch; it may 
remain open to the end of the third year. The top of the head presents a 
flattened, square appearance due to thickening of parietal and frontal emi- 
nences. In young infants soft and yielding spots, due to thinning of the 
bone in the parietal and occipital regions, are found ; these patches may be 
from y 2 to 1 inch in diameter. This condition, known as craniotabes, is 
not more characteristic of rickets than it is of syphilis; it occurs in both 
conditions and is very commonly associated with the syndrome of laryngis- 
mus stridulus. 

Blood Changes. — According to Morse, a number of forms of anemia 
may occur, the red cells are slightly reduced, and the hemoglobin very 
much so, from 30 to 40 per cent. The specific gravity is reduced and 
leukocytosis is present when the spleen is markedly enlarged. 

The mucous membranes of rachitic infants are especially prone to catar- 
rhal inflammations from slight causes. Gastrointestinal catarrh, coryza, 
pharyngitis, laryngitis, bronchitis, and pneumonia are common complica- 
tions of rickets. 

Course. — Rickets is a chronic disease and its duration will depend on 
its severity and the character of the treatment instituted. In mild cases, 
under proper treatment, it may be cured in three or four months. In severe 
cases the active symptoms may last from eighteen months to two years. 
Many of the rachitic deformities are permanent. 

Congenital rickets is a rare disease. It does, however, occur in 
utero ; infants are born with craniotabes, the rickety rosary, and other char- 
acteristic bony changes; this form of the disease is especially rare in 
America. 

Late rickets, occurring in children from six to ten years of age, is 
very uncommon. In these cases the bony deformities develop rapidly. I 
have seen but one case, a girl seven years of age in whom there rapidly de- 
veloped a softening and bending of the bones of the legs and other charac- 
teristic symptoms. Braces were applied and treatment instituted. The 
child recovered after ten or twelve months' treatment. 

Diagnosis. — The diagnosis of well-marked rickets is easily made and 
attention will only be directed to the fact that it should be made in most 
cases much earlier than it is. If nervous, irritable children, who have been 
fed on a food rich in starch and poor in fat and protein, show general lack 
of development, late teething, open fontanels, muscular weakness, and head 
sweating during sleep, a diagnosis of rickets should be made without wait- 
ing for the disease to proclaim itself by its more characteristic symptoms. 

Prognosis. — The prognosis in cases of mild rickets is very good; the 
disease, in this stage, contributes little or nothing to the mortality list. 



TREATMENT 243 

Severe rickets, however, is a very grave disease and contributes largely to 
the death list in our large cities ; not that rickets itself is so dangerous, but 
it reduces the vitality pf the infant to such a low ebb that it readily suc- 
cumbs to catarrhal diseases of the gastrointestinal and respiratory tracts, as 
well as to convulsive disorders which are such common complications of rickets. 

Treatment. — Prophylaxis. — Since rickets is such a common disorder 
in artificially fed infants, and since the disease can, as a rule, be prevented 
by careful feeding and proper hygiene, the physician should have in mind 
the prophylactic treatment of rickets in the feeding of every baby that 
comes under his care. In breast-fed babies the prophylactic treatment of 
infants is not, as a rule, difficult ; it is only necessary to be sure that they 
have a sufficient amount of good breast milk, and, where there is any doubt 
upon this question, to supplement the breast feedings with properly modi- 
fied fresh cow's milk, according to the rules outlined under Mixed Feed- 
ing. If the breast milk is sufficient and of proper quality, it is safest to 
continue to feed the baby exclusively on breast milk for nine months and 
then to supplement the breast feedings with fresh, clean cow's milk. In 
artificially fed infants, however, the problem is a very different one. It is 
easy enough to write out a milk formula for an infant with normal digestive 
capacity which will furnish it with the proper number of calories and with 
the proper percentages of fat, protein, salts, and carbohydrates to prevent 
the development of rickets. But there are other infants, born of delicate 
parentage, suffering from mild forms of glandular tuberculosis or other 
constitutional diseases; premature infants and infants who because of gas- 
trointestinal disorders have a feeble digestive capacity; these are the cases 
that give us trouble and that force us to a compromise which results in a 
food formula which the infant can digest, but which may fail to fully 
supply its nutritional demands. In these cases it is difficult for even the 
most experienced physician to carry the infant through the first year with- 
out the development of at least a mild form of rickets, unless a wet-nurse 
is employed. 

Curative Treatment. — From what has been said it is clear that the 
important factor in the treatment of rickets is the diet. The disease has 
developed upon a food formula which failed to meet nutritional demands, 
and this formula is commonly rich in carbohydrates and poor in fat, pro- 
tein, and salts, such as we find in condensed milk, Nestle's food, malted 
milk, and other proprietary foods which do not require fresh cow's milk in 
their preparation. It follows, therefore, that it is absolutely necessary to 
success in the treatment of rickets, that the food upon which the infant has 
developed the disease should be either radically changed or greatly modi- 
fied. A mistake, however, which is very common and which, as a rule, is 
fraught with disastrous results is a too radical change in the diet. Many 
rachitic infants, when they come under the observation of the physician, 
have for a long time been fed upon one of the easily digested proprietary 
foods and have, therefore, such feeble digestive capacity that they cannot 
at once be placed upon cow's milk. If such a radical change is attempted 



244 RICKETS 

in these cases it is probable that gastrointestinal disturbances will be added 
to the other rachitic symptoms. It is necessary, therefore, in changing the 
food, especially of infants with advanced rickets, to make haste slowly. One 
may, perhaps, in these cases begin by adding skimmed raw milk to the food 
the infant is already taking and gradually increasing the milk so as to 
develop the digestive capacity. In this way the original proprietary food 
mixture may be gradually replaced by skimmed milk and later by whole 
milk, until a food formula is reached which in fat and proteins will serve 
the nutritional demands of the infant. It may be necessary in some in- 
stances to use peptonized milk to gradually replace the proprietary food and 
then later to gradually diminish the peptonization until the baby is on a 
suitable raw-milk formula. If the infant has developed rickets on steril- 
ized milk this food must be replaced by raw milk. By this gradual process 
of eliminating an unsuitable food the child may be placed upon a proper 
food mixture without producing digestive disturbances. The object in 
every instance being to increase the proteins, fat, and salts and diminish the 
carbohydrates, but in doing this great care must be taken to prevent over- 
feeding ; the value of the food mixtures in calories should at no time greatly 
exceed the nutritional demands of the infant. It is also wise to feed all 
rachitic infants at a four-hour interval; more frequent feedings are gen- 
erally fraught with disastrous results. 

In the second year of life soft-boiled eggs are a very important adjunct 
to the dietetic treatment; the yolk of the egg furnishing the fat and the 
white the albumin. Meat juice and beef peptonoids may also be of value 
in those cases where the idiosyncrasies of the child make it impossible to 
put it upon a proper milk formula. Butter is a palatable and easily di- 
gested fat which may be given on bread or in a cereal with milk. Eaw or 
partially cooked, scraped beef is a food of great value when it can be prop- 
erly cared for by the digestive organs of the child. 

Fresh air and sunshine are curative measures of the greatest importance. 
There can be no doubt that the fresh air and sunshine of the country, under 
suitable climatic conditions, are of themselves direct curative agents, but 
their greatest importance lies in the fact that they very materially increase 
the digestive capacity of the infant for fat and proteins, and thereby hasten 
the time when it can be placed upon a proper diet. 

Cod-liver oil is, next to a suitable diet, the most valuable remedy we 
have in the treatment of rickets, and the excellent results which come from 
its use seem to indicate that its great value does not altogether lie in the 
fact that it is an easily assimilated fat. The administration of cod-liver 
oil, however, should not be begun, in advanced cases, until we have par- 
tially solved the food problem as outlined above ; but in mild cases it should 
be begun at once and in severe cases as soon as the physician believes that 
the digestive capacity of the infant will permit of its administration. As 
a rule, cod-liver oil is well tolerated by rachitic infants; it should be admin- 
istered over a long period of time in connection with the dietetic treatment. 
The form in which cod-liver oil is given will depend upon the individual 



TREATMENT 245 

idiosyncrasies of the infant; it should be discontinued if it produces lack 
of appetite or gastrointestinal disturbances; it is perhaps best given com- 
bined with one of the malt extracts. These preparations are palatable and, 
as a rule, improve the digestive capacity of the infant. In individual in- 
stances, however, it may be better to give the pure oil or one of the palat- 
able emulsions. For an infant six months old the dose may be from 15 to 
20 minims three times a day, and for an infant one year of age twice this 
amount. Phosphorus, so highly recommended by Kassowitz and Jacobi, is 
of value in the treatment of rickets; the dose should be from 1/200 to 
1/250 of a grain. It may be given in the form of Thompson's solution of 
phosphorus, which may be mixed with whatever form of cod-liver oil prep- 
aration the infant is taking. Iron, in the form of the saccharated carbonate 
or some other easily assimilated preparation, is of value where there is 
marked anemia with an enlargement of the spleen and lymph nodes. It is, 
however, advisable to get the infant well started on a proper food formula, 
so as to have its convalescence well under way, before beginning the admin- 
istration of iron. 

Salt baths have been recommended and are perhaps of some value dur- 
ing the acute stage of the disease. 

Oil inunctions are believed to be of value throughout the whole course 
of the disease. Mild general massage, followed by inunctions of anhydrous 
lanolin, are of value in improving nutritional conditions. This treatment 
gives mild exercise to the wasted muscles and joints and also gives the in- 
fant a certain amount of fat, which is taken up by the lymphatics and 
blood vessels of the skin. 

Prevention of Deformities. — The prevention of deformities is one of 
the most important duties which the physician has to observe in the treat- 
ment of acute rickets. During the active stage of the disease, while the 
bones are soft and flexible, it is most important that the infant should be 
prevented from assuming positions that will result in bony deformities. It 
should lie upon its back on a smooth mattress, and, when it is handled, care 
should be taken that long-continued pressure in any one position may not 
result in the curvature of bones. It should be discouraged from walking, 
crawling, and sitting alone until the treatment has been continued long 
enough to overcome the softness and flexibility of the bones. It may in 
some instances be necessary, if the child is slow in its recovery, to resort to 
braces and other supports to prevent curvatures of the spine and of the 
bones of the leg. 

Treatment of Rachitic Deformities. — There is a tendency on the 
part of nature to gradually overcome the deformities which result from the 
contraction of the ribs, the curvature of the spine, and the distended abdo- 
men. She may be assisted in her laudable purpose by subjecting the child 
to systematic gymnastic exercise under the guidance of a competent in- 
structor. The surgical treatment of old rachitic deformities, especially of 
the long bones, is of great value, but this is a subject which belongs to the 
field of orthopedic surgery. 



246 INFANTILE SCUEVY 

CHAPTEE XXX 
INFANTILE SCUEVY 

(Scorbutus) 

Definition. — Scurvy is a chronic nutritional disorder due to a prolonged 
absence or diminution of certain food constituents which are absolutely 
necessary to normal metabolic processes; the exact nature of this food de- 
ficiency is not altogether clear. The medical world inclines to believe with 
Barlow, Northrup, Crandall, and others, that infantile scurvy is the same 
disease as scorbutus in the adult ; the clinical picture being modified, as it 
is in so many other diseases, by the somewhat different chemical and bio- 
logical problems found in the immature and rapidly developing organism of 
the infant. Eickets and scurvy are so commonly associated in the infant 
that for many years there was great confusion in their differential diagnosis, 
it being commonly believed that scurvy in the infant was a manifestation 
of rickets. In recent years, however, the well-recognized hemorrhagic 
tendency of infantile scurvy and its general resemblance to scorbutus in 
the adult have led to the very general belief that it is an independent affec- 
tion commonly associated with, but not otherwise related to, rickets either 
in its etiology, pathology, or treatment. 

Etiology. — Infantile scurvy is for the most part a disease of the first 
and second years of life; the great majority of cases occur between the sixth 
and the eighteenth month ; it rarely begins before the third month or after 
the second year. It occurs more frequently in infants of the middle and 
upper classes, because they are not uncommonly fed on a food which at 
some time or other in its preparation has been subjected to superheating; 
in this it differs markedly from rickets, which is more common among the 
poor because of the ill-balanced food formulas upon which these infants 
are fed. 

Diet. — Some dietetic error is the all-important cause of the develop- 
ment of scurvy. The report of the American Pediatric Society's Collective 
Investigation of Infantile Scurvy in 1898 showed that of 379 cases the 
food upon which the disease developed was as follows : 

Breast-milk in 12 cases, alone in 10 

Eaw cow 's milk in 5 cases, alone in 4 

Pasteurized milk in 20 cases, alone in 16 

Condensed milk in 60 cases, alone in 32 

Sterilized milk in 107 cases, alone in 68 

Proprietary infant-foods in 214 cases. 

This report shows that scurvy most commonly develops on the propri- 
etary foods, sterilized milk, condensed milk and pasteurized milk and that 
it very uncommonly develops on raw cow's milk and breast milk. In most 
of the cases in which scurvy has developed on breast milk, the milk is either 



SYMPTOMATOLOGY 247 

defective in composition, as shown by chemical analysis, or exclusive breast 
feeding has been continued for too long a time. 

In studying the dietetic causes of scurvy one is led to the conclusion 
that the fault must lie chiefly in the absence of some fresh principle in the 
food, which is either destroyed, chemically changed, or rendered less diges- 
tible or assimilable by heat. It is evident that heat may act by destroying 
active biological properties of the food which are necessary in infantile 
metabolism, or it may act by producing changes in the acids and salts of 
fresh foods ; these acids and salts being in part separated from their protein 
combinations by heat and their biological and chemical value thereby im- 
paired in the body metabolism. Whether or not this be the explanation, 
the fact remains that food that has been biologically killed by heat, as in 
the sterilization of milk or in the preparation of proprietary foods, is re- 
sponsible for over 90 per cent, of the cases of infantile scurvy. The char- 
acter of the food formula, which is all-important in the etiology of rickets, 
has little to do with the production of scurvy, and the fact that the pro- 
prietary foods which are such a prolific cause of scurvy in infants are also 
ill-balanced in the percentages of their important ingredients, explains why 
scurvy and rickets are so commonly associated in the same infant. A food 
that contains too little fat, protein, and salts may produce rickets, while, on 
the other hand, as a result of the changes which heat has produced in it, it 
may produce scurvy. 

A very small percentage of the cases occur in children fed on breast 
milk and on raw cow's milk. That these unusual cases cannot in every in- 
stance be explained by a chemical analysis of the milk does not militate 
against the fact that food that has been changed by heat is the all-important 
cause of this disease. When scurvy occurs in an infant fed on breast milk 
or raw cow's milk the rational conclusion is that this particular milk has 
suffered some important chemical or biological change, even though the 
science of chemistry may not be able to reveal its nature. 

Morbid Anatomy. — The characteristic changes are produced by hemor- 
rhages which may be very widespread; the most notable are the subperios- 
teal hemorrhages of the long bones, which may be very extensive along their 
shafts and at their epiphyseal junction. The diaphyses and epiphyses of 
these bones may separate, causing marked deformities. Hemorrhages may 
also occur in the medullary canals and characteristic changes occur in the 
bone marrow, which becomes poor in cells and blood vessels. The muscles, 
the pleura, the pericardium and peritoneum may be the sites of small hem- 
orrhages, and the gums are spongy and hemorrhagic. In a large percent- 
age of the cases the minute changes occurring in bones are similar to those 
seen in rickets, but these changes are caused by the rickets, which is so com- 
monly associated with scurvy, and do not belong properly to the pathology 
of this disease. 

Symptomatology.- — Tenderness of the legs and sometimes of other por- 
tions of the body is one of the earliest and most characteristic symptoms ; 
this is manifested by the infant crying when it is handled and by its re- 



248 INFANTILE SCURVY 

maining quiet when it is allowed to rest in its bed. The importance of this 
sign is emphasized by the fact that the natural instincts of the infant are 
here reversed; if an infant, contrary to all the instincts of its nature, cries 
and frets when it is taken up and fondled by its mother and becomes quiet 
again when it is replaced in bed, this can only be explained by the fact 
that the handling causes pain. This leads to the suspicion that the child 
has been injured, and an investigation on the part of the mother often 
confirms her in this belief, since she finds that the child, even when lying 
in its bed, will cry with pain when some particular portion of the body is 
moved. A further investigation may develop the fact that the legs are 
tender to the touch and are swollen about the knees and ankles. These 
swellings are commonly fusiform in shape and are due to the subperiosteal 
hemorrhages, which may extend from the ankle to the knee, and, being 
more marked near these joints, may in severe cases cause a separation of 
the epiphyses and diaphyses. The soreness and tenderness produced by 
these swellings cause the infant to hold its legs as motionless as possible, 
thus producing the pseudo-paralysis of scurvy. This false paralysis results 
from the tense condition of the muscles which holds the legs immovable and 
is perhaps the result of reflex rather than of voluntary action on the part 
of the infant ; this condition of immobility is even greater when the spinal 
column is involved. The severity of these symptoms grows apace as the 
disease advances, until the infant is in a pitifully helpless condition, scream- 
ing with pain at the slightest movement or crying out with fear when it is 
approached by the physician. In these severe cases the sternum may be 
separated from the ribs and sunken backward, producing a characteristic 
deformity. 

Hemorrhage into the gums is an early and characteristic symptom. The 
gums may be purple and swollen and when teeth are present hemorrhages 
are more frequent; they may bleed when touched and there may be evi- 
dences of spontaneous petechial hemorrhages in the vault of the pharynx 
and other parts of the mouth. Hemorrhages may occur from other mucous 
membranes, as is evidenced by the fact that blood is occasionally found in 
the feces and in the urine. They may also occur in the subcutaneous tis- 
sues about the joints and other parts of the body, as well as in the con- 
junctiva and orbit. In this latter position they may produce exophthalmos. 

Enterocolitis may be present in severe cases. The child is irritable, 
anemic, and suffers from general malnutrition; in advanced cases the 
anemia and malnutrition are very marked. The blood findings may be 
those of an ordinary secondary anemia or they may be of the chlorotic type. 
The urine not uncommonly contains albumin and casts. In advanced cases 
fever is usually present, but it is inconstant and irregular in type and is 
perhaps due to intestinal and other complications. 

Diagnosis. — The crying of the infant on being taken up, the swelling 
and tenderness of the joints, the hemorrhagic condition of the gums, and 
the history of the child having been fed upon a food which may develop 
scurvy, are commonly sufficient to make the diagnosis. In making a differ- 



TREATMENT 249 

ential diagnosis, however, the physician should remember that rheumatism 
presenting the above symptoms very rarely, in fact almost never, occurs in 
infancy, but if rheumatism, osteomyelitis, or periostitis be suspected in an 
infant presenting the above symptoms, the differential diagnosis of these 
diseases from scurvy can be readily made by the dietetic treatment subse- 
quently outlined. 

Prognosis. — The prognosis, when the disease is recognized early, is good. 
In neglected cases which have come into the hands of the physician too late 
to respond to treatment, death may occur from malnutrition, enterocolitis, 
pneumonia, or hemorrhage. 

Treatment. — Prophylactic treatment is of the very greatest im- 
portance. In many instances the physician, especially in dispensary prac- 
tice, is forced to superintend the feeding of an infant during the hot months 
of summer, where the conditions are such that he must use foods, the long 
continuance of which may produce scurvy. When these sterilized and 
cooked foods are given for any length of time it is certainly the part of wis- 
dom to direct that from time to time these infants be given a certain 
amount of orange juice. This will effectually prevent the development of 
scurvy. 

The curative treatment of scurvy is almost as simple as the prophy- 
lactic treatment and consists in giving the infant some kind of fresh or 
uncooked food, either with or as a substitute for the food which it has been 
taking. Fresh fruit juice is a specific for scurvy. Orange juice is gen- 
erally used, because it can be obtained at any season of the year, and because 
it more commonly agrees with the infantile digestive organs than other 
fruit juices. One may begin by giving a teaspoonful of orange juice, 
slightly sweetened, if necessary, five or six times a day. An existing gas- 
troenteritis does not contraindicate.the use of orange or other fruit juices. 
Under this therapeutic measure the pain and tenderness about the joints 
may disappear in four or five days, and a cure may confidently be expected 
within two or three weeks. As the child improves and the gastrointestinal 
condition becomes normal, the amount of orange juice may be increased to 
six tablespoonfuls in the twenty-four hours. It may be advisable to give 
fresh beef juice in connection with the fruit juices in the beginning of the 
treatment. Later, potatoes that have been steamed and mashed and the 
juice of fresh vegetables may be given with advantage. The mistake is 
very commonly made in advanced scurvy of immediately attempting to 
substitute a diet of fresh cow's milk for the proprietary food upon which 
the infant has been living. There can be no question as to the advisability 
of such a procedure provided the infant's digestive capacity is equal to 
the change. But in most instances this change has to be brought about 
very gradually and should not be begun until the infant has commenced to 
respond to the specific treatment above noted; the change to fresh cow's 
milk is then brought about as rapidly as the infant's digestive capacity will 
permit. The raw cow's milk itself, like the fruit juices, has a curative 
influence and is also necessarv to remove the malnutrition which has re- 



250 



DIABETES MELLITUS 



suited from the scurvy and concurrent rickets. As the infant improves, 
the orange juice and beef juice are continued and cod-liver oil and iron are 
given. The cod-liver oil is especially valuable in those cases where rickets 
complicates the scurvy. 



CHAPTER XXXI 
DIABETES MELLITUS 



In the infant and young child diabetes, as a rule, runs a rapidly fatal 
course; the younger the child the more rapid and the more fatal is this 
disease. It rarely occurs in infancy, but is occasionally seen in the young 
child. 

The etiology and pathology of diabetes in the child are the same as 
in the adult. 

Symptomatology. — Among the earliest symptoms noted are thirst, fre- 
quent urination, loss of weight and strength, lassitude, and anemia. An 
increased thirst and appetite causes the child to drink large quantities of 
water and to eat more than the normal amount of food. An excessive 
quantity of urine is passed, having a high specific gravity, containing large 
quantities of glucose, and later acetone, diacetic, and oxybutyric acids are 
found. As the disease progresses the child loses in weight and strength, its 
appetite begins to fail, its insatiable thirst continues, the intake of water 
becomes greater and greater, the quantity of urine is proportionately in- 
creased, it becomes irritable and restless, the skin and mucous membranes 
are dry, furunculosis may develop, an acetone odor may be detected on the 
breath, and finally a somnolence followed by diabetic coma may terminate 
in death. 

Treatment. — The treatment of diabetes in the child is the same as in 
the adult. The quantity as well as the quality of the food is important. 
The child should be given only a sufficient number of calories to supply its 
nutritional needs, and the diet should be made up of the ordinary diabetic 
foods prescribed for adults. In beginning the treatment it is even more 
important than it is in the adult that the patient should be placed upon a 
strictly diabetic diet and that the quantity of water which the child takes in 
twenty-four hours should be limited as much as possible. If the urine, 
upon a strict diabetic diet, can be made sugar-free there is a chance that 
under careful dietetic management life may be prolonged for many years, 
and that a cure may be effected in a small percentage of cases. It is neces- 
sary, however, after the urine has remained sugar-free for a few weeks, that 
certain carbohydrates should be added for the purpose of developing a toler- 
ance for this class of foods. The carbohydrates which are thus to be added 
in small quantities to the diet should be first oatmeal, then potatoes, and 
later small quantities of wheat bread. The dietetic management, however, 
of these cases cannot be discussed in detail here, since this chapter is a long 



EECUEEENT VOMITING 251 

one and may be found in any modern textbook on medicine. The point 
to be emphasized is that unless the child can be got into a condition in 
which it can metabolize certain carbohydrates such as those mentioned, 
without causing an increase of sugar in the urine, the case is a hopeless one. 



CHAPTEE XXXII 
EECUEEENT VOMITING, EECUEEENT CORYZA AND MIGEAINE 

RECURRENT VOMITING 

Synonyms. — Cyclic vomiting, lithemic vomiting, migrainous gastric 
neurosis, periodical vomiting, bilious vomiting, vomiting with acetonemia. 

Definition. — Eecurrent vomiting, which is one of the most common dis- 
eases of early childhood, is an autointoxication produced by systemic and 
probably intestinal toxins. It is characterized by recurring attacks of 
nausea, persistent vomiting, prostration, and the appearance of acetone 
bodies in the urine. 

Etiology. — Liver Incompetency. — The failure on the part of the liver 
to neutralize or destroy systemic and intestinal toxins is, I believe, the 
most important cause of this disease. This hypothesis assumes that the 
liver, from various causes, the chief of which is overwork, more or less sud- 
denly develops a functional incompetency which renders it incapable of 
converting ammonia and the purin bodies into urea and destroys its so- 
called filtering function, which normally renders innocuous the fermenta- 
tion products which pass through it from the intestinal canal. As a result 
of this liver inactivity both systemic and intestinal toxins escape into the 
general circulation and produce an autointoxication which is named from 
its most prominent symptom "Eecurrent Vomiting." After a few hours or 
days, as the case may be, the liver resumes its function and the acute attack 
of autointoxication is ended. In those very rare cases where this condition 
terminates fatally there is a well-marked fatty degeneration of liver cells. 
Howland's and Eichards' investigations indicate that the chief metabolic 
disturbance underlying recurrent vomiting is deficient oxidation and also 
that the products of intestinal fermentation (indol, etc.) are more or less 
directly responsible for the symptoms. There are many factors, predispos- 
ing and exciting, which in individual cases help to produce the liver incom- 
petency which causes this widely varying symptom group. This variability 
may be explained by the fact that it is not always produced by the same 
autotoxins. In one group of cases the intestinal toxins may dominate, 
and in another the systemic; in still another the autointoxication may.be 
almost or quite overshadowed by nervous symptoms produced by powerful 
exciting causes. In these cases the symptoms of hysteria and other neuroses 
may be commingled with those of autointoxication. 

Exciting Causes. — Overeating is perhaps the most common of all ex- 



252 KECUKKENT VOMITING, COKYZA, AND MIGKAINE 

citing factors. Individual idiosyncrasies with reference to the metabolism 
of certain food stuffs are most important; defective carbohydrate metabol- 
ism is very commonly present in infants and children, to such a degree that 
an excess or even ordinary quantities of sugars and sometimes of starches is 
quickly followed by attacks of autointoxication; an inability to metabolize 
excessive quantities or even normal quantities of fat is also very common; 
defects in protein metabolism are less rarely seen. In some instances, fol- 
lowing a "food injury" to the metabolism from an excessive intake of either 
fats or sugars, the child for months or years may not be able to take even 
comparatively small quantities of one or other of these foods without 
producing an attack of recurrent vomiting. In time, however, under care- 
ful feeding it may gradually recover its normal powers of metabolizing 
these foods. Food idiosyncrasies are not confined to fats and sugars; acid 
fruits, certain vegetables, eggs, or milk may in individual cases be followed 
by attacks. The trouble in such cases is not solely a question of digestion, 
but also one of metabolism. Food idiosyncrasies, therefore, must be looked 
for in every case. 

Among other exciting causes may be mentioned mental and physical 
fatigue, mental excitement, nervous strain, fright, anger, acute infections, 
general anesthesia, especially by ether, and severe reflex irritation originat- 
ing in the eye, nasopharynx, or genitourinary organs. 

The acidosis which occurs, in recurrent vomiting is, in most cases, a 
very important part of the pathological process and when well pronounced 
no doubt contributes to the production of the clinical syndrome of this 
disease. It may occur early or it may appear late, and in a small minority 
of cases it is not present at all. It is not to be considered as an etiological 
factor, but rather as an important symptom of this condition. The path- 
ology of acidosis is elsewhere discussed. 

Predisposing Causes. — Heredity is a most important predisposing fac- 
tor; a family history of migraine, gout, or neurotic disease is present in 
most cases. Constipation is nearly always present. Eecurrent vomiting 
occurs more frequently among children of the upper classes. Mental over- 
work and nerve excitement, combined with indoor life and confinement in 
ill-ventilated rooms, are important factors. The great majority of cases 
occur during infancy and childhood. I have seen the first symptoms ap- 
pear as early as the third month, but it is most commonly seen between the 
third and tenth year; after this period the tendency is to spontaneous re- 
covery, or to a change in form of the autotoxic attacks in which vomiting 
plays a secondary role. They may gradually be transformed in the older 
child and adult into true migraine. They are slightly more common in 
girls than in boys and are seen more frequently in winter than in summer. 

Symptomatology. — General Symptoms. — The following description 
presents the ordinary type of this disease. There is usually a prodromal 
period lasting from a few hours to a few days. This may be characterized 
by sallowness of complexion, dark rings under the eyes, general malaise, 
constipation, coated tongue, disagreeable odor to the breath, loss of appe- 



RECURRENT VOMITING 253 

fcite, gastric discomfort, anorexia, nausea, general nervous irritability, 
sleeplessness, flushing of the cheeks, and possibly coryza, dyspnea, and 
sighing respirations. The stools may be white or putty-like in color with 
a disagreeable odor. Not all of these prodromes are present in any one 
case, but in an individual case the same prodromal symptoms commonly 
precede the recurring attacks. Occasionally, without warning, the attack 
may be ushered in with vomiting, quickly followed by fever. In some of 
my cases the attacks were always preceded by a vasomotor coryza. 

Vomiting. — This is the most constant and most characteristic symp- 
tom. In the beginning it may not be severe, but in a few hours it may 
become very violent and associated with retching, the vomitus containing 
hydrochloric acid, mucus, bile and rarely blood; in the interval between 
the attacks there may be nausea. The vomiting may continue for a few 
hours, or it may last eight or nine days; when it continues for any length 
of time it produces great emaciation, is associated with great prostration 
and is accompanied by insatiable thirst. When the vomiting subsides 
the gastrointestinal canal quickly resumes its functions; food is taken 
without the slightest discomfort, convalescence is rapid, and, within from 
four to nine days, the patient has fully recovered. Subsequent attacks 
occur at irregular intervals, and it is this recurrence which leads to their 
differentiation from acute gastritis. When second or third attacks of 
vomiting, in which the same symptom group is reproduced, occur in spite 
of careful feeding and without apparent cause, the physician must suspect 
their autotoxic character and make the necessary examinations of the urine 
and stomach contents which confirm the diagnosis. While it is the rule 
that patients suffering from recurrent vomiting have little or no gastric 
or intestinal disturbance in the interval, yet this is a rule which has 
many exceptions, especially in children under four years of age. In the 
very young child these autotoxic attacks may manifest themselves by a 
difficulty in digesting cow's milk, and gastric indigestion associated with 
vomiting and mild intestinal fermentations may intervene between the 
more pronounced attacks of recurrent vomiting. 

Pain is usually absent; this is especially true of recurrent vomiting 
as it occurs in the child. In those cases where the autotoxic attacks are 
continued into adult life severe pain in the head or stomach may be asso- 
ciated with the vomiting. 

Constipation, which commonly precedes the attack, becomes more ob- 
stinate as the attack goes on, and it is one of the most difficult symptoms 
to relieve because the irritable condition of the stomach will not tolerate 
cathartic medication. When the constipation is relieved by cathartics the 
discharges are putrid. Diarrhea occurs in rare instances. 

In severe cases the emaciation and prostration are rapid and extreme ; 
the abdomen is boat-like or flattened, the eyes are sunken and the face has 
an anxious expression. 

Fever from 101° to 105° F. is present in nearly every case; the younger 
the child the more marked the febrile reaction. In the older child the tern- 



254 EECUEEENT VOMITING, COEYZA, AND MIGRAINE 

perature may not rise above normal. After the second or third day the tem- 
perature subsides and may become subnormal. The pulse is rapid and usu- 
ally irregular. The breathing may be but slightly disturbed, or it may be 
rapid and panting; in some cases there is dyspnea with wheezy respira- 
tory sounds. The peculiarly sweet and rather offensive acetone odor 
of the breath is a striking symptom ; as a rule it occurs early, and in a few 
instances is never present. When once observed, it is easily recognized 
and may be so penetrating that it is noticed on entering the room. As 
the disease progresses the tongue, pharynx and lips become dry and irri- 
tated. Toward the close of a severe attack there is a tendency to som- 
nolence, and a prolonged sleep is frequently followed by the first indica- 
tions of improvement. 

Children who suffer from recurrent vomiting are usually precocious 
and neurotic. They present varying degrees of general nervous excitabil- 
ity and restlessness, even in the interval between the attacks. In very 
nervous children, as Snow has noted, convulsions may occur. 

Urine. — The acetone bodies are the most characteristic findings in 
the urine. In the milder cases acetone alone may be found, in those of 
moderate severity both acetone and diacetic acid, and in more severe cases 
oxybutyric acid is also present. The urine is scanty, concentrated and 
hyperacid and in severe cases albumin and hyalin casts are present. In- 
dican, indolacetic acid, uric acid, and the xanthin bodies are markedly 
increased during the attack. Howland and Eichards report an increase in 
the unoxidized sulphur and a diminution in sulphuric acid. 

The Blood. — A leukocytosis of 16,000 to 20,000 commonly occurs, 
with a relative increase in the small lymphocytes. 

Diagnosis. — The periodical return of the symptom group is a most 
important diagnostic indication. The presence of free hydrochloric acid 
in the vomited matter may materially assist in differentiating this condi- 
tion from acute gastritis, and the urine findings above noted, with the 
absence of pain and abdominal tenderness, should differentiate it from 
appendicitis and intestinal obstruction. 

Prognosis. — It should be remembered that this is one of the most com- 
mon disorders of childhood and that in most instances it will be overlooked 
if systematic examinations of the urine for acetone and diacetic acid are 
not insisted upon. The prognosis, as far as recovery from the attack is con- 
cerned, is good; death, however, may occur from exhaustion or from a 
terminal nephritis; only a few fatal cases have been reported. The prog- 
nosis as to the prevention of these attacks is also good. Under proper 
medical supervision the attacks cease, the improvement in the child's 
general health continues, and as it grows older its nervous system becomes 
more stable and a tendency to these recurring attacks is thus outgrown. 
Untreated cases may later be transformed into migraine or, rarely, into 
epilepsy. 

Clinical Types. — It should be understood that there are many variations 
in the clinical syndromes grouped under the general heading Eecurrent 



RECURRENT VOMITING 255 

Vomiting. The attack may not proceed beyond the prodromal symptoms; 
in many cases there may be little or no vomiting, and the characteristic 
syndrome may be marked by a periodic return of fever lasting one or two 
days, associated with a coated tongue, bad breath, lack of appetite, nausea 
and constipation. In other instances, especially in older children, the 
prodromal symptoms of recurrent vomiting may occur associated with 
nausea, headache and narcotism, and in still another group the same pro- 
dromal symptoms may be associated with a recurrent coryza or a recur- 
rent asthma, which may or may not be accompanied by nausea and occa- 
sional vomiting. If one remembers that the symptom group above out- 
lined may present itself in all grades of severity, but that in the same 
individual these attacks closely resemble one another, there will be little 
difficulty in making a diagnosis. 

There is another syndrome associated with a marked acidosis described 
by Thomas D. Parke, which my experience leads me to believe is a dis- 
tinct clinical entity due to some severe toxemia. It occurs most commonly 
in children under three or four years of age. The symptoms in the 
beginning are those of acute gastrointestinal infection. There is diarrhea 
and nausea and commonly an acetone odor to the breath. The stools 
usually contain mucus and blood, are passed with more or less straining 
and are frequently preceded by intestinal colic. Labored and rapid breath- 
ing is a prominent symptom. The liver is enlarged. There may be a 
slight fever, but as the disease progresses the temperature becomes sub- 
normal. There is marked prostration and the disease commonly comes to 
a fatal termination with an increasing gastrointestinal irritation and a 
marked increase of the acetone bodies in the urine. This symptom group 
is much more severe, much more dangerous and differs materially from 
the ordinary syndrome of recurrent vomiting. The fatal cases terminate 
within three or four days after the onset of severe symptoms. The post- 
mortem findings show an enlarged liver, which has undergone fatty de- 
generation, and there may be fatty degeneration of other organs. Apart 
from this the pathological findings are not definite. 

Treatment.— Treatment of the Attack. — If seen in the prodromal 
stage, one-fourth of a grain of calomel and five grains of bicarbonate of 
soda should be given every half hour until two grains of calomel are 
taken, and two or three hours later a saline laxative should be given. This 
should be followed by five or ten grains of bicarbonate of soda every two 
or three hours over a period of several days, administered in carbonated 
water, plain water or peppermint water. No food whatever should be 
allowed for at least twenty-four or thirty-six hours, or until the nausea and 
vomiting have been controlled. After the attack is well on the nausea 
and vomiting may preclude not only all food, but all stomach medication. 
The calomel and bicarbonate of soda, however, may be tried at any stage 
of the attack, and if the nausea and vomiting are not aggravated they 
may be continued. At intervals throughout the attack water may be allowed 
in small quantities, even though the stomach rejects it; when the patient 
18 



256 RECURRENT VOMITING, CORYZA, AND MIGRAINE 

is able to retain water, then small quantities of thin beef broth may be 
given. If water is not retained by the stomach it is advisable to give, at 
intervals of six or eight hours, high rectal enemata of 6 or 8 ounces of 
physiological salt solution, or of a 1 per cent, bicarbonate of soda solution. 
Edsal's suggestion that large doses of bicarbonate of soda be given by the 
mouth is a good one in those cases where the soda is retained, but the great 
discomfort and exhaustion which follow attacks of vomiting teach us that 
it is wise, when the stomach is very irritable, to let it have a period of 
prolonged rest and then attempt to give bicarbonate of soda by the mouth 
in 8- or 10-grain doses every two or three hours. In the most aggravated 
cases, where prostration is extreme and vomiting has continued over a num- 
ber of days, 8 to 16 ounces of sterile physiological salt solution combined 
with five or ten grains of bicarbonate of soda to the ounce may be injected 
into the subcutaneous tissues. In this same type of case the hypodermic 
use of morphin frequently controls the vomiting, and may, like hypo- 
dermoclysis, be a life-saving measure. Small doses of from 1/20 to 1/60 
of a grain of morphin, depending upon the age of the child, are usually 
sufficient to control the irritability of the stomach long enough to allow 
the bicarbonate of soda solution given by the mouth to be absorbed. 
When necessary the morphin and the hypodermoclysis may be repeated 
at intervals of eight to twelve hours. 

Interval Treatment. — When the child is convalescent causes of 
reflex irritation to the nervous system should be carefully sought for and 
removed. Constipation, which is usually present, must be relieved; this 
may be done by palatable solutions of sulphate and phosphate of soda. 
These saline laxatives are advisable in beginning the treatment; later cas- 
cara sagrada, rhubarb and other cathartics may be used; enemata are not 
to be relied upon. Abdominal massage may relieve the constipation. 
General massage is one of our most valued remedies in overcoming the 
constitutional conditions which predispose to recurrent vomiting; it is 
especially indicated in patients of feeble constitution who are not strong 
enough to enjoy the benefits of outdoor life and. active exercise. 

In the early interval treatment of this condition the wintergreen sali- 
cylate of soda and the benzoate or bicarbonate of soda put up in palatable 
solution are our most valued remedies; two grains of the salicylate and 
five grains of the bicarbonate may be given to a child six years of age 
over a period of months. After three or four months these remedies may 
be given once or twice a day for a year or more, as the indications may 
direct. If during this time the prodromal symptoms of an attack make 
their appearance, the calomel and bicarbonate of soda are to be given 
as previously directed, and then the salicylate and bicarbonate of soda 
are to be resumed. From a very large experience I have the greatest faith 
in the efficacy of the interval-medical treatment as here outlined. It may 
be necessary occasionally to interrupt the alkaline treatment and substitute 
such tonics as malt and arsenic; after a time, however, it is necessary to 
return to the alkaline treatment. 



EECUEEENT VOMITING 257 

In the treatment of recurrent vomiting in older children I use the 
formula which I originated many years ago for the treatment of migraine. 
It is as follows : 

Sodii sulphatis (dry) 30 grains 

Sodii salicylatis (from wintergreen) 10 grains 

Magnesii sulphatis 50 grains 

Lithii benzoatis 5 grains 

Tincturae nucis vomicae 3 drops 

AqusB destil. to make • 4 ounces 

This prescription is put up in siphons and charged with carbonic acid, 
and the child is directed to take, half an hour before breakfast, a suffi- 
cient quantity to produce at least one bowel movement during the morn- 
ing. This prescription is a remedy of great value in the preventive 
treatment, not only of recurrent vomiting, but also of migraine; it may in 
fact replace all other medication. 

Dietetic Treatment. — This is of very great importance. In begin- 
ning the treatment all sweets, fats, raw fruits, strawberries, rhubarb, 
tomatoes, salads, tea, coffee, beef-juice, beef-tea, pastry, gravies, cream, 
cod-liver oil and alcohol are to be avoided, and the child should not be 
allowed to eat large quantities of meat. The following foods may be recom- 
mended: skim-milk, vegetable soups, cereals, well-cooked vegetables, cooked 
fruits, bread, eggs, fish, chicken, mutton and beef. It is most important 
that children suffering from recurrent vomiting should be guarded against 
an excess of food of any kind and that sweets of all kinds should be care- 
fully excluded. It will be found that in certain instances the sweets are 
the prime cause of the trouble, while again in other cases the attacks can- 
not be controlled until the fats are eliminated from the diet. The diet 
of the child should be carefully balanced; if, for example, he happens to 
be an excessive meat eater, the meats should be somewhat restricted and 
a proper proportion of vegetables, cooked fruits, or cereals given, and the 
child should also be made to cultivate the habit of drinking as much water 
as possible. 

Hygienic and Climatic Treatment. — As suboxidation is one of the 
essential underlying pathological processes of this disease, it is necessary 
that the child should have as much fresh air and outdoor exercise as pos- 
sible. Most of these children prefer an indoor life and intellectual pur- 
suits, so that it becomes necessary for the physician to give special direc- 
tions with reference to open air sleeping apartments and the number of 
hours of outdoor play which the strength of the child and the season of 
the year will permit. A change of climate in many instances may be ad- 
visable to avoid the extreme heat of summer and the damp cold of winter. 
These children should, as a rule, be taken out of school. Mental stim- 
ulation, nervous excitement and all forms of mental and physical fatigue 
should be avoided until their physical and nervous condition justifies a 
return to the ordinary routine of child-life. 



258 RECURRENT VOMITING, CORYZA, AND MIGRAINE 



RECURRENT CORYZA 

There is a form of coryza, recurring at irregular intervals without ap- 
parent local or external cause, which is self-limited and is closely related 
in its etiology and pathology to recurrent vomiting. 

Symptomatology. — Constipation, loss of appetite, general nervous irri- 
tability and sallowness of skin may be prodromes. The attack itself comes 
on with an acute congestion of the nasal mucous membrane, accompanied 
by a profuse, irritating, thin mucous discharge from the nose, which pro- 
duces redness and swelling of the lip over which it flows ; at the same time 
there is commonly an acute congestion of the mucous membranes of the 
eyes, marked by a redness and swelling of the conjunctiva, intense photo- 
phobia, and a profuse overflow of tears. These symptoms come on rapidly 
and are associated with a state of extreme nervous irritability. The pa- 
tient seeks a darkened room, buries her head in the pillows, or shields her 
eyes with her hands when light is admitted. These attacks are self-limited ; 
the symptoms continue in the worst cases for four or five days, and then 
quickly subside. Convalescence is very rapid; within two or three days 
after the symptoms begin to disappear the patient is quite well, showing 
little or no evidence of disease of the mucous membranes, which were so 
recently the site of extreme irritation. These attacks recur from time to 
time at irregular intervals, very like those of recurrent vomiting and mi- 
graine, and in the interval between the attacks there may be no evidence 
of disease of the mucous membranes of the eye and nose. The above 
description represents the severe type of this disorder. In milder cases 
the attack may manifest itself as a more or less severe coryza with- 
out the eye symptoms, and may in this form occur as one of the pro- 
dromes of an attack of recurrent vomiting. Vasomotor coryza is not 
uncommonly associated in its clinical manifestations with an urticaria of 
the skin. 

The treatment in every particular is similar to that of recurrent vom- 
iting. 

MIGRAINE 

Migraine is an autointoxication due to systemic or intestinal toxins 
which find expression in recurrent self-limited attacks of severe paroxysmal 
headaches, usually unilateral, commonly accompanied by nausea, vomit- 
ing, vertigo, and visual phenomena and followed by a profound sleep from 
which the patient awakes free from pain. 

Migraine is not often a disease of early childhood. The great major- 
ity of cases appear in late childhood or early adult life. 

It is very similar in its etiology and pathology to recurrent vomiting.. 
It may, however, be noted that reflex factors such as eye-strain, diseases 
of the nasopharynx and of the genitourinary and pelvic organs, play a 
more important role as exciting causes in touching off an attack of mi- 



MIGBAIKE 259 

graine than they do in producing recurrent vomiting. I have in a num- 
ber of instances seen the recurrent vomiting attacks of early childhood 
become attacks of true migraine in late childhood and adult life. 

The treatment of migraine occurring in childhood is similar to that 
above outlined for recurrent vomiting. 



SECTION VI 
INFECTIOUS DISEASES 

CHAPTEE XXXIII 
FEVER 

Fever is the most common symptom of illness in infancy and child- 
hood. At this period of life there is such a predisposition to fever that 
high temperatures may occur from comparatively slight causes, and for 
this reason the direct exciting cause of the fever is not always apparent 
at the beginning of the child's illness. The physician must frequently 
wait until the second day, or perhaps later, before he can determine the 
nature of the pathological disturbance. In the meantime he must pre- 
scribe for the sick child and be directed in the selection of a diet and other 
remedies along such lines as his general experience teaches him are the 
safest and the most likely to bring good results under existing conditions. 
In thus prescribing for a syndrome of which fever is the most important 
symptom, the physician's judgment must be largely directed by his knowl- 
edge of the most common exciting causes of fever at different ages in the 
life of the child, as well as by the accompanying but as yet inconclusive 
symptoms with which the fever is associated. For the above reasons an 
inquiry into the most common direct causes of fever at different periods 
in the life of the child should be of the greatest practical importance to 
physicians in enabling them to begin the treatment of these cases in a way 
to give the most satisfactory results. 

In the chapter on Growth and Development I have discussed the 
physiological peculiarities of the heat-regulating mechanism of the young 
nervous system and have there shown that the tendency to high fever from 
comparatively trivial causes at this time of life is due to the marked 
excitability of the thermogenic centers and the feeble control which the 
inhibitory centers exercise over them, and have also called attention to the 
fact that the very efficient heat-dissipating mechanism of this period of 
life acts as a protecting agency, and by its quick response reduces these 
high temperatures. This rapid play of function between the heat-generat- 
ing and heat-dissipating functions accounts for the great variability of the 
temperature curve which characterizes the fevers of childhood. A sus- 
tained temperature with little variations is rarely seen in the infant or 

260 



EXCITING CAUSES OF FEVER 261 

child, except in lobar pneumonia and typhoid fever, and even in these we 
have greater variations in the temperature curve than we do in the same 
conditions in the adult. In the same chapter I emphasized the fact that 
the tendency of the individual child to high and variable temperatures 
might be greatly exaggerated by a neurotic inheritance, a chronic mal- 
nutrition or unfavorable environment. It is evident, therefore, that apart 
from the unfinished and unstable condition of the heat-regulating mechan- 
ism of the child, the most important predisposing causes of fever are to 
be found in all those conditions which produce the malnourished and ab- 
normally nervous child. These have been previously discussed in the 
chapter on The General Hygiene of Infancy and Childhood. This leaves 
for our discussion here the direct exciting causes of fever. 

Exciting Causes of Fever. — The most common exciting causes of fever 
in infancy and childhood may be classified as follows : 

1. Intestinal toxemia, commonly of bacterial origin, but including also 
the "food injuries" described under Acute Intestinal Indigestion. 

2. Systemic toxemia of bacterial origin. 

3. Systemic autointoxication of non-bacterial origin. 

4. Heat-stroke. 

5. Mechanical and reflex irritation, including simple indigestion. 

6. Muscular action (convulsive) and over-fatigue. 

Intestinal toxemia is by far the most common and the most im- 
portant cause of fever in children under two years of age; this is especially 
true of artificially fed infants. This fact alone is of the very greatest 
importance in directing the physician along proper lines of therapeutic ac- 
tion. In a child under two years of age, especially if it is being fed upon 
artificial food, elevation of temperature, the causes of which cannot be 
ascertained, may be assumed to be due to intestinal toxemia and treated 
accordingly until a positive diagnosis can be made. There are many other 
causes which may produce fever in children at this time of life, but the fact 
remains that under the above-named conditions a tentative diagnosis of 
gastrointestinal toxemia is shown by later developments, in the great ma- 
jority of cases, to be the true one, and above all it offers a safe and wise 
course for therapeutic action. The influence of free catharsis and absti- 
nence from food upon the temperature curve in these cases will materially 
assist in confirming the diagnosis. If under these measures the tempera- 
ture falls and remains low, it is a safe inference that intestinal intoxication 
was the cause of the fever, but, if following this treatment there is no fall 
in the temperature, or if following the fall there is a subsequent rise of 
the temperature, which is not influenced by catharsis and starvation, the 
inference is that the fever with its accompanying symptom group is due to 
other causes than intestinal intoxication. 

Systemic intoxication of bacterial origin is the most common 
cause of fever in children over two years of age, and the older the child 
the more important becomes this factor as a fever producer. In children 
over three years of age, an elevation of temperature without apparent cause 



262 FEVER 

commonly means the child is suffering from tonsillitis, influenza (la 
grippe), pneumonia or one of the other acute infectious diseases. Whatever 
may be the subsequent course of the temperature curve in the various 
acute infections, they are almost always announced by an early rise in 
temperature, and the distinctive symptoms which complete the symptom 
group and make possible an accurate diagnosis may not appear until the 
second or third day, or even later. In these cases it is always wise to 
isolate the sick child from the well ones in the family. A preliminary 
cathartic, a light diet, and some such medicine as aspirin or phenacetin, 
to control the fever and nervous symptoms, are indicated until the diag- 
nosis is made. 

Systemic autointoxication of non-bacterial origin plays a rather 
important role in producing fever in infants and young children. The 
fever, however, from this cause cannot be differentiated from that produced 
by one of the acute infections until symptoms, such as occur in uremia, 
acidosis and other intoxications, present themselves to complete the auto- 
toxic syndrome. The clinical picture produced by these conditions is else- 
where described under Recurrent Vomiting. The preliminary treatment 
of these cases, even if we knew from the beginning the character of the 
disease, would be that of free catharsis and abstinence from food. 

Heat-stroke, as Forchheimer has long taught, is an important cause 
of fever in infancy and childhood. Probably the best explanation of the 
fever of heat-stroke is that the feeble inhibitory heat centers of the child 
are still further weakened by the heat, so that practically no restraint is 
exercised over the thermogenic centers. This explains the fact that the 
younger the infant the more prone is it to have elevations of temperature 
from exposure to excessive heat. In the premature infant the body tem- 
perature may be raised far above normal by the unwise application of 
hot water bottles and other forms of external heat. During the summer 
season many of the so-called cases of cholera infantum with high temper- 
atures and other severe symptoms are due to excessive heat. In these cases 
the heat acts directly as a fever producer and also indirectly in keeping 
up the fever by producing a gastrointestinal fermentation. High fever in 
a young infant that has been exposed to unusual heat should be attributed 
to this cause, and should be treated by ice-bags to the head, tub-baths, 
free catharsis and abstinence from food until the character and cause of 
the fever have been definitely determined. 

Direct mechanical and reflex irritations may produce an eleva- 
tion of temperature in the young infant. It is important to remember 
that a purely reflex fever may occur during infancy. These fevers are, 
as a rule, evanescent and of comparatively little pathological importance. 
They occur very infrequently in normal, well-nourished infants, but they 
are of very common occurrence in nervous, malnourished ones. The cut- 
ting of a tooth, undigested food, worms, foreign bodies in the intestinal 
canal, and excessive pain (earache) are among the most common causes 
of reflex elevations of temperature. Slight elevations of temperature 



OBSCUBE FEVEES OF INFANCY AND CHILDHOOD 263 

therefore occurring in nervous, malnourished infants may be due to the 
coming through of a tooth, or to undigested food in the intestinal canal, 
and elevations of temperature with violent and prolonged paroxysms of 
crying should lead to a careful examination of the ear. The preliminary 
treatment, however, of these cases is the same as that previously outlined 
for intestinal toxemia, and their subsequent history will establish the 
diagnosis and direct more specific treatment. 

Excessive muscular action may cause an elevation of temperature 
in infants and young children. The manifestation of muscular energy is 
always accompanied by the formation of heat, and excessive muscular ac- 
tion, such as occurs in general convulsions, may be accompanied by an 
increase in the body temperature; the elevation of temperature, therefore, 
at the close of a convulsion may be higher than at its beginning. . This 
cause of increased temperature, however, is of comparatively little impor- 
tance. Over-fatigue may cause an elevation of temperature in nervous, 
malnourished children. The rise in temperature from this cause usually 
occurs in the afternoon and may reach to 101 °F. A slight afternoon rise 
of temperature in this type of child should be treated by fresh air and 
rest for a few days, and if the fever still continues it is due to other 
causes. 

In the above study of the causes of fever I have attempted to furnish 
the data which will assist one in arriving at a fairly accurate determina- 
tion of the cause of a fever occurring as the initial symptom of an acute 
illness, and I have also attempted to indicate the safe and rational thera- 
peutic measures with which the treatment of acute febrile cases should be 
begun. There is in the obscure fevers of infancy and early childhood a 
field of diagnostic and therapeutic inquiry quite as important as that upon 
which we have just dwelt. In the "obscure fevers " the difficulty in diag- 
nosis continues after the onset of the initial symptoms. In some of these 
cases the failure to make the diagnosis is due to carelessness, insufficient 
knowledge, or lack of facilities on the part of the physician; in others 
the symptoms and physical findings do not form a syndrome sufficiently 
clear to warrant a definite diagnosis. For these reasons it is important 
that the physician should have constantly in mind the most common 
causes of, and the most rational treatment for, these "obscure fevers." 

Obscure Fevers of Infancy and Childhood. — Holt's (inanition) fe- 
ver is the most common cause of fever during the first four or five days of 
life ; in fact, fever rarely occurs at this time from any other cause. Holt's 
fever is a clearly defined s} r ndrome; the elevation of temperature usually 
occurs on the second or third day of life and disappears by the fifth or 
sixth; it requires no treatment other than the giving of water or breast- 
milk. It is elsewhere described. 

Sepsis is the most important cause of fever during the second week 
of life. Continuous fever occurring at this time, not associated with di- 
gestive disturbances, is in the great majority of instances due to sepsis, 
and the septic infection commonly finds an entrance through the open um- 



264 FEVER 

bilical wound. Since sepsis in the new-born is a disease of great gravity, 
an unexplained fever during the second week of life is sufficient cause for 
alarm and demands that other symptoms of sepsis should be carefully 
looked for and that the treatment for this disease should be at once in- 
stituted. 

Lobar pneumonia is a common cause of obscure fever in the infant. 
The fever of this disease is not only high, but is more sustained than that 
of any other fever of infancy. A high temperature curve that runs its 
course with little variation, occurring in an infant under two years of 
age, is strongly suspicious of lobar pneumonia. This fact is important, 
since in many cases of lobar pneumonia in the infant the physical signs 
are not discoverable until the fourth or fifth day. A sustained high tem- 
perature, therefore, occurring without apparent cause in an infant, should 
be treated as a lobar pneumonia until a definite diagnosis is made. 

Otitis media is perhaps the most common cause of obscure fever in 
children under two years of age, and is not an uncommon cause in older 
children. The fever of otitis media is subject to wide variations; at one 
time during the day it may reach 104° or 105 °F., and at another be almost 
or quite normal. Otitis media as the cause of fever is perhaps more gen- 
erally overlooked than any other disease ; for this reason it should be a rule 
of practice to examine the ear and look for other signs of otitis media in 
all the unexplained fevers of infancy and early childhood. It is not al- 
ways associated with earache, but when this symptom is present, the violent 
fits of crying should at once call attention to the ear as the cause of trouble. 

Pyelocystitis, although nothing like so common as pneumonia or 
otitis media, is not an uncommon cause of obscure fever in infancy and 
early childhood. Unless the physician be on the alert, these cases are 
nearly always overlooked and the fever is attributed to some other cause. 
The fever of pyelocystitis is much more irregular than that of lobar pneu- 
monia and very commonly there are few or no symptoms to call attention 
to the genitourinary organs. For this reason, unless the physician makes 
it a rule to examine the urine in all the obscure fevers of infancy and 
early childhood, these cases may run on for weeks without attention being 
called to the bladder or kidneys as the site of the infection. 

Tuberculosis is the most common cause of continued fever of obscure 
origin in children over four years of age. The tuberculosis of childhood, 
as I have elsewhere said, is usually concealed, and one of its earliest man- 
ifestations is a slight irregular fever. As the disease progresses the tem- 
perature may rise to 103° or 104° F., but it commonly falls to normal or 
below normal during the day. The tuberculosis of infancy (that is to say 
under two years of age) is not a concealed disease; it runs a rapid and 
much more serious course and is not commonly manifested as an obscure 
fever. In children, therefore, over four years of age a long-continued ir- 
regular fever, without apparent cause, should strongly suggest tuberculosis, 
and the diagnosis can usually be confirmed by other signs and symptoms 
outlined in the chapter on that disease. 



OBSCUEE FEVERS OF INFANCY AND CHILDHOOD 265 

Typhoid fever is not an uncommon disease after the second or third 
year of life. During childhood it may be classed among the obscure fe- 
vers, since the nervous and abdominal symptoms, which are so character- 
istic in the adult, are commonly absent in the young child. The fact that 
typhoid fever in the child, like lobar pneumonia in the infant, is the most 
common cause of high and sustained fever is very important from a diag- 
nostic standpoint. Every fever occurring at this period of life that runs 
a high course with comparatively little variation should be tentatively 
diagnosed as typhoid and treated as such until further developments make 
the diagnosis clear. The Widal reaction commonly makes the diagnosis in 
these cases, but even in the presence of a negative Widal the case should 
be treated as typhoid until other causes for the fever are discovered. In 
some instances the Widal test is not positive until the second or third week 
of the disease, and then again there is a group of cases produced by the 
paratyphoid, the bacillus enteritidis, and perhaps other organisms, which 
have all the clinical characteristics of typhoid fever and yet never show 
the Widal reaction. 

Subacute and chronic intestinal toxemia may be the cause of 
obscure fever in infancy and early childhood. In these cases a temperature 
from 101° to lOl 1 /^ ^. m ay be present in the afternoon with a normal or 
subnormal temperature in the morning, and there may be little, on casual 
examination, to call attention to the intestinal canal as the cause of the 
disturbance. On closer inspection, however, it will be found that the in- 
testinal discharges are not normal. They may be fragmentary, putrid, 
and covered with more or less mucus, and an examination of the urine will 
show a marked increase in indican or indolacetic acid. Suitable cathartics 
from time to time with a carefully regulated diet will control the temper- 
ature if intestinal toxemia is the exciting cause. 

Septic infection is not an uncommon cause of obscure fever through- 
out childhood. The temperature curve of sepsis, which runs from 103° to 
105° F. at one time during the day and falls to 96° or 97° F. at another, 
is so suggestive of sepsis that septic infection is commonly suspected with 
this type of temperature, although the localization of the sepsis may be 
very obscure. In these cases the presence of an increasing polynuclear 
leukocytosis may confirm the diagnosis. If an examination of the ear 
excludes otitis media, the bronchial or cervical lymphatics or the mastoid 
may be suspected as the possible site of the sepsis. In older children the 
antrum or frontal sinus may harbor the infection, and in some cases we 
may have a general septicemia which runs its course to a fatal or favor- 
able termination without apparent localization. In the great majority of 
instances septic infection in infancy and childhood occurs as the sequel 
or as a complication of one of the acute infectious diseases; under such 
conditions the physician, being prepared for the development of septic 
symptoms, rarely fails to make the diagnosis, although he may have trouble 
in locating the focus of infection. 

Treatment. — In the treatment of obscure fevers it is wise to begin 



266 FEVEK 

with a cathartic such as small doses of calomel followed by castor oil. 
This preliminary clearing of the intestinal canal can do no harm in any 
form of fever and is of value in reducing the temperature even though the 
intestinal canal be not the site of the disease. Throughout the course of 
the fever the intestinal canal should receive careful attention; constipa- 
tion, intestinal fermentation and diarrhea are to be treated by appropriate 
remedies, whatever may be the cause of the fever. 

Diet. — A fluid diet, free from milk or other albuminous foods, should 
be prescribed for the first twenty-four or thirty-six hours, or until it has 
been determined that intestinal intoxication is not the cause of the fever. 
In children over three years of age having a sustained temperature, a 
typhoid diet should be prescribed until it is proven that the disease is not 
typhoid; this rule will prevent many gross dietetic errors. Jacobi says: 
"In ordinary fevers the food must be liquid and rather cool; in vomiting, 
cold; in respiratory diseases, warm; in collapse, hot. The best feeding 
time is the remission; in intermittent fevers nothing must be given dur- 
ing the attack except water, or acidulated water, now and then with an 
alcoholic stimulant; in septic fevers, nothing during a chill, except either 
cold or hot water, according to the wishes of the patient, with alcoholic 
stimulant. Common ephemeral catarrhal fevers may do without food (ex- 
cept water) for a reasonable time. Sleep must not be disturbed, except 
in conditions of sepsis and depressed brain action. In both there is no 
sound sleep, but sopor, which should be interrupted. In sepsis this rous- 
ing from sopor is an absolute necessity. Unless they are aroused fre- 
quently to be fed sufficiently and stimulated freely, the patients will die. 
Besides, in most of the cases the temperatures are not high, and there is no 
contraindication to feeding on that account. Chronic inflammatory fe- 
vers bear and require feeding as generous as it must be careful." 

Antipyretics. — The ice-bag not too closely applied to the head is one 
of the most valuable measures we have for the control of high tempera- 
tures in the infant and child. In the application of this remedy, however, 
it is necessary that the patient should be under the observation of a com- 
petent nurse, since there is some danger in very young and delicate in- 
fants that the prolonged application of ice to the head may produce a sub- 
normal temperature. This should be guarded against by careful tempera- 
ture records, so that when the temperature approaches normal the ice-bag 
may be removed; in older children this danger does not exist. The ice- 
bag when properly applied is not only a satisfactory antipyretic measure, 
but it exercises a very pronounced influence over the nervous symptoms 
which accompany the fever. The bath is the safest and most effective 
agency we have for reducing the body temperature. It is important to 
remember that the cold bath does not always act as kindly in infants as 
it does in older children. Frail and nervous infants do not react well 
from the cold bath; the shock to the nervous system produced by the 
sudden application of cold water to the body may do more harm than 
good. The temperature of the bath must be regulated by the age and 



ETIOLOGY 267 

strength of the infant. In young and delicate infants a warm or tepid 
bath, or a sponge bath with alcohol and warm water, will, when combined 
with the use of the ice-bag in the interval between the baths, reduce the 
body temperature and exercise a sedative influence on the, nervous system. 
In older and sturdier children cool baths and cold packs may be given 
with signal advantage, but it is rarely necessary to use a bath below 80 °F. 
Phenacetin and aspirin in doses suited to the age of the child may be 
safely used for the control of the temperature in the early stages of the 
ephemeral fevers of childhood. These medical antipyretics should be used 
only during the first twelve or twenty-four hours of the fever and then 
only for controlling unusually high temperatures which are associated 
with marked nervous symptoms. They should not be used in the prolonged 
fevers associated with marked prostration. Fever patients should, if pos- 
sible, be put to bed and kept there until the temperature has reached 
normal. They should also be isolated from other children and shielded 
from all unnecessary excitement. 



CHAPTER XXXIV 

TYPHOID FEVEE 

Typhoid fever is an acute infectious disease caused by the typhoid 
bacillus. It is a general infection characterized by a more or less typical 
temperature curve, and by the involvement of lymphoid tissues, especially 
Peyers patches and the spleen. 

Etiology. —The typhoid bacillus, which is the specific cause of this 
disease, was first described by Eberth. It is cylindrical with rounded ends, 
crowned with cylia, and is from 1 to 3 /i in length and from .5 to .8 /a. 
in diameter. It has marked motility in liquid media and grows readily at 
body temperature in common culture media. It is destroyed at l-iO°F., 
but resists low temperatures; it can live for months in ice and in ordinary 
drinking water. On clothing soiled with typhoid feces or urine the bacilli 
may. if not exposed to light and desiccating processes, live for weeks. This 
extraordinary vitality under adverse circumstances enables it to live and 
thrive in every part of the globe from the tropics to the Arctic regions ; it 
is therefore practically a world-wide disease. It is but slightly pathogenic 
for other animals than man; Grunbaum has produced the disease in chim- 
panzees. Other living creatures may harbor the bacilli in their intestinal 
canals and elsewhere, and act as typhoid carriers, even though they present 
no symptoms of typhoid fever. The typhoid bacillus is to be distinguished 
from a group of similar organisms to which it belongs, such as the bacillus 
enteritidis. the colon, and the paratyphoid bacillus A and B, all of which 
are capable of producing clinical syndromes closely simulating typhoid 
fever. The bacillus enteritidis and the paratyphoid B are believed to be 
the chief causes of meat-poisoning. 



268 TYPHOID FEVER 

Source of Infection.— It is a generally admitted fact that the intestinal 
canal and lymphoid tissues of man furnish the most favorable culture 
conditions for the growth of the typhoid bacilli. The tendency is to an 
increase in virulence as the bacilli pass from host to host in the course of 
an epidemic, so that the early cases may be mild and the later ones severe. 

Method of Infection. — Drinking water, contaminated by the fecal or 
other discharges from typhoid patients, is the common cause of the spread 
of this disease. Wells, or the general water supply of cities, may be con- 
taminated by sewage and thus cause epidemics of typhoid fever. Too much 
stress cannot be laid upon the importance of contaminated drinking water 
as the great cause of typhoid fever. Milk, being a good culture media, 
may be a carrier of this infection; many small epidemics have been traced 
to this source. In such instances the milk is usually contaminated by 
an infected water supply, the water being used in diluting the milk or 
washing the pails. Ice-cream made from contaminated milk may produce 
typhoid fever. 

Flies may act as carriers of typhoid infection to milk and other food 
materials of man. The danger from the fly is greatest in country districts 
and where large bodies of people are camping under conditions which per- 
mit it to come in contact with fecal discharges ; in the city, where sanitary 
plumbing prevails, it has fewer opportunities to act as a carrier. Shell- 
fish, especially oysters and clams which are eaten raw, may be a source 
of infection when contaminated by sewer discharges. The contagion is 
rarely, if ever, . carried through the air ; the surroundings of the patient, 
except as they are fouled by excretory discharges, are not a source of dan- 
ger; direct infection, however, does occur to nurses and others who are in 
close contact with the patient, but such infection is avoidable if proper 
methods of cleanliness and disinfection are used in the care of the pa- 
tient. The contaminated bed-clothing, if not properly disinfected, may be 
a source of danger to the laundress or to the household into which it is 
carried. Well individuals who have had typhoid fever may, in rare in- 
stances, harbor in their intestinal canals typhoid bacilli and thus act as 
typhoid carriers, unconsciously spreading contagion among those with whom 
they come in close contact. 

Occurrence.— Typhoid fever occurs most commonly during the months 
of August, September and October ; Osier calls it an autumnal fever. Dur- 
ing the first year of life it is comparatively rare, and in the second year 
it still remains a rather uncommon disease, but thereafter susceptibility 
rapidly increases up to the twentieth year. 

Pathology. — Typhoid fever is a general infection; the bacilli of this 
disease may be found in every part of the body. They are present in the 
intestinal canal, the blood, the rose-spots, all the viscera and especially in 
the spleen, mesenteric glands and gall bladder. The lesions produced, 
while similar to those found in the adult, are much less pronounced and 
extensive. The solitary follicles and Peyer's patches are enlarged and may 
be ulcerated. The spleen is greatly enlarged, in nearly every instance 



SYMPTOMATOLOGY 269 

being two or three times its normal size. Slight parenchymatous degen- 
eration of the liver and kidneys, myocardial weakness, hyperemia and even 
inflammation of the meninges, pneumonia, middle ear suppuration and 
parotid abscess may occur. As a rule the older the child the more nearly 
does the pathological anatomy conform to that of the adult type, and the 
younger the child the more important is the typhoid septicemia. 

Fetal Typhoid. — The bacilli of typhoid fever may pass from the mother 
through the placental circulation to the fetus; in about one-half of these 
cases abortion or premature labor results, and the fetus is born dead; in 
other cases the child is born with typhoid fever of the septicemic type, 
and death commonly results within the first week ; fetal typhoid is a disease 
with very great mortality; few cases recover. On the other hand, newly- 
born infants, born of mothers who have had typhoid fever during the 
period of their gestation, may show the Widal reaction; in such cases it is 
probable that the child had typhoid fever in utero or that the agglutinating 
principle in its blood was received through the placental circulation. 

Period of Incubation. — The Spanish- American Commission found that 
the average period of incubation for typhoid fever was ten and a half days. 
In a study of a local epidemic which I reported in 1901, nine days was 
the shortest and nineteen days the longest period of incubation; the ma- 
jority had an incubation period of less than ten days. 

Symptomatology. — General Symptoms. — While in a general way the 
symptoms of typhoid fever in the child resemble those in the adult, yet it 
should be remembered that the younger the child the more are these symp- 
toms modified in their course and in their severity, so that the symptom- 
complex is radically different from that of the adult. In the very young 
infant there is a general typhoid septicemia without marked local symp- 
toms, but as the child grows older the clinical syndrome gradually changes, 
giving more and more prominence to the characteristic symptoms as they 
occur in the adult. It may also be said that the younger the child the 
more irregular the onset of this disease ; in infancy it may be marked by 
acute prostration, vomiting, sudden rise of temperature and all the evi- 
dences of a sudden and general toxemia. In such instances typhoid fever 
may not be suspected until the symptoms of the acute toxemia have sub- 
sided, leaving a continuous fever with other symptoms which suggest the 
possibility of this disease. In children three or four years of age the on- 
set is commonly marked by headache, a general infection and a gradual 
rise of temperature. The severity of the disease cannot be predicted from 
the suddenness or violence of the onset. The course of typhoid fever in 
young children, if not prolonged by complications, is mild and brief 
as compared with that in the adult; under three years of age it may not 
extend over fourteen days; in 80 cases observed by Henoch, 11 lasted less 
than ten days, 26 less than fifteen days, 16 less than twenty days, 21 from 
twenty to thirty days, and 6 over thirty days. 

Fever. — The temperature curve in childhood is not so regular and 
characteristic as it is in the adult. The first stage may be short, the tern- 



270 



TYPHOID FEVEE 



perature rising rapidly to its maximum within two or three days, and the 
third stage or the stage of decline may be marked by great variations, 
the temperature assuming a markedly remittent or even intermittent type, 
while the second stage may show an almost continuous temperature with 
little variation between the morning and evening temperature (Morse). 
In very young children this sudden rise of temperature with the onset of 
the disease and its rapid fall toward the close may not be a matter of prog- 
nostic importance, but in older children a sudden fall of temperature oc- 
curring during the height of the disease should suggest perforation or in- 
testinal hemorrhage. Secondary rises in the temperature after the disease 
has apparently run its course may result from relapse or from some com- 



of Sonth 10 II 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 


of disease 1 2 3 4 5 6 7 8 9 10 II 12 13 14 15 16 17 18 


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Fig. 42. — Typhoid Fever in Child Two and One-half Years of Age. 



plication. Very mild cases of typhoid fever running a short and almost 
afebrile course are more frequently observed in children than in adults. 

The pulse, which in the adult is so valuable a prognostic sign, is not of 
such great importance in the young child. A dicrotic, rapid and intermit- 
tent pulse occurring during the height of the disease, in the adult, is a 
danger signal of great importance. In very young children a pulse of 170 
may occur and not be of serious import. In older children the pulse is 
commonly slow, varying from 70 to 90, but even at this age dicrotism and 
intermittency do not, as a rule, presage danger. On the whole, therefore, 
much less information is obtained from a study of the pulse in children 
than in adults. Systolic murmurs at the apex and rarely at the base are 
common; they usually appear in the third week of the disease as the acute 



SYMPTOMATOLOGY 



271 



symptoms subside, and many continue for weeks after convalescence has 
been established. 

The exanthem consists of slightly elevated rose-spots about the size of 
a pin's head, which disappear on pressure. These spots are distributed 
over the abdomen and back ; in some cases being few in number and widely 
scattered, in others more numerous and grouped in patches. They com- 
monly appear from the fifth to the eighth day, but may occur earlier or 
later. In rare instances they may assume a dark blue or hemorrhagic ap- 
pearance. In some instances an erythema may precede this typical ex- 
anthem, but is of no special importance, except that it may complicate the 
diagnosis. Sudamina may be present; toward the close of the disease fine 



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Fig. 43. — Typhoid Fever; Child Six Years of Age. 



desquamation occurs. In protracted cases furunculosis, or small subcu- 
taneous abscesses, may be widely distributed over the body and greatly add 
to the discomfort of the patient, prolonging the disease. 

Enlargement of the spleen is almost always present in typhoid fever; 
it begins early in the disease and gradually increases to three or four times 
its natural size. It can commonly be made out by palpation on the third 
or fourth day, and for this reason is of very great diagnostic value. It 
gradually subsides with the other acute symptoms, but it can very com- 
monly be demonstrated after convalescence has been established ; in relapses 
it again increases in size. 

Digestive Tract. — Abdominal Symptoms. — Vomiting occurs much 
more frequently in children than in adults and is one of the early symp- 
19 



272 



TYPHOID FEVER 



toms. Constipation is common, especially between the ages of three and 
seven, and is usually obstinate enough to require laxative medicines for its 
relief. It is very frequently associated with gastrointestinal toxemia, 
which aggravates and prolongs the disease. In quite young children 
typhoid fever may begin with a sharp diarrhea resembling an acute in- 
testinal toxemia; in these cases, however, the intestinal irritation may 
quickly subside and the subsequent course of the disease be marked by a 
mild diarrhea or even by constipation. In older children diarrhea is 
the rule, the discharges being frequent and having the characteristic pea- 
soup appearance. Meteor ism is rarely a marked symptom in the young 
child; in older children it may render difficult the palpation of the spleen 
and the percussion of liver dullness. In the young child abdominal pain 




Fig. 44. — Typhoid Fever; Child Ten Years op Age. 

is not usually present, and gurgling and tenderness in the right iliac region 
cannot commonly be made out. 

Intestinal hemorrhage and intestinal perforation are very rare under 
six years of age. From the tenth to the fifteenth year, however, they are 
not so uncommon and are marked by the same symptoms as in the adult. 

The tongue is white, but the tip and edges are clean and dark red in 
color; later the coating gradually disappears from before backward, giv- 
ing it a bright red appearance with dark red papillae standing out prom- 
inently. The dry, fissured, dark, coated tongue covered with sordes is 
rarely seen in the child and can be much more readily prevented by mouth 
disinfection in the child than it can be in the adult. 

Nervous Symptoms. — The nervous symptoms of the child differ 
markedly from those of the adult; they are much less common and much 
less severe ; the low muttering delirium and the profound stupor are rarely 
observed. In the vast majority of cases the nervous symptoms are confined 
to headache, restlessness, irritability, apathy and perhaps a tendency to 
somnolence, mild delirium, and transitory delusions. It should, however, 
also be noted that the following nervous symptoms, although very unusual, 



THE GRUBER-WIDAL REACTION 273 

may occur : convulsions, stupor, meningism, neuritis, hemiplegia, aphasia, 
melancholia and acute mania. 

Respiratory Tract. — Epistaxis, one of the early symptoms of adult 
typhoid, is rare in the child. 

A mild bronchitis is common in typhoid fever. Broncho and lobar 
pneumonia are serious, but rare complications. 

Urine. — The diazo reaction of Ehrlich occurs in 60 to 80 per cent, 
of the cases ; it makes its appearance about the end of the second week and 
increases in intensity while the disease is at its height. Its value as a 
diagnostic sign is impaired by the fact that it is found in measles, tuber- 
culosis, malaria, meningitis, pneumonia, and some of the other acute in- 
fections ; it is absent, however, in influenza. Acetonuria may occur. Acute 
nephritis is rare, but a trace of albumin is not uncommon. 

Blood. — Simple anemia gradually develops with a like reduction in 
corpuscles and hemoglobin. The leukocytes progressively diminish in num- 
ber; in severe cases they may be reduced to 2,000. The differential count 
shows a relative increase in mononuclears and decrease in polymorphonu- 
clears and eosinophiles. An increase in leukocytes to over 10,000 indicates 
some form of septic or inflammatory complication. 

The Gruber-Widal Reaction. — This is the most valuable of all signs or 
symptoms in the diagnosis of typhoid fever. It is perhaps less accurate 
than blood cultures, but the simplicity of its technique, bringing it within 
the scope of the general practitioner, gives it a value in diagnosis which 
perhaps will never be obtained by blood cultures. This reaction depends 
upon the fact that the defensive mechanism of the body, in its antagonism 
to typhoid bacilli, produces certain substances called agglutinins, which 
have the power of agglutinating and rendering motionless the typhoid 
bacillus. If the blood of a typhoid fever patient, containing these ag- 
glutinins, be combined with a bouillon culture of typhoid bacilli, it will 
readily clump them and stop their motion. When this occurs the test is 
said to be positive. It is commonly made under the microscope, but 
macroscopic tests have also been devised. The Gruber-Widal reaction is 
perhaps a more valuable diagnostic sign in children than in adults, as it 
occurs earlier in the disease and in a larger percentage of cases. In the 
average it may be said to occur in 95 per cent., and is commonly found as 
early .as the seventh or eighth day. This reaction continues for a long time 
after the patient has recovered from typhoid, so that a positive Widal may 
date from a previous attack. In estimating the diagnostic value, there- 
fore, of this test, care must be taken to determine whether the patient has 
ever had typhoid fever ; with this excluded a positive Widal associated with 
an otherwise unexplained acute febrile condition justifies the diagnosis 
of typhoid. A positive Widal reaction may occur in jaundice, but so rarely 
in other conditions as to be practically negligible. A negative Widal 
reaction does not necessarily preclude the diagnosis of typhoid, as the ex- 
amination may have been made before the agglutinins have developed in 
sufficient quantities to produce a reaction, or the case may belong to that 



274 



TYPHOID FEVEE 



small percentage in which the reaction never occurs. Blood cultures nearly 
always give definite information of the existence of typhoid before a posi- 
tive Widal can be obtained. At the present time, however, this method of 
diagnosis is largely confined to hospital practice. In this examination a 

bouillon culture material is in- 
oculated with blood obtained 
from a vein in the arm and 
after twelve or twenty-four 
hours is examined for typhoid 
bacilli. As the laboratories 
in our cities become better 
equipped and the technique of 
the operation simplified, this 
. method of diagnosis may be- 

come more generally used in 
fe private practice. 
m Relapses. — Relapses occur 
< in from 10 to 15 per cent, of 
^ the cases; Blackader reports 
w fifteen relapses in 100 cases; 
£ second and even third relapses 
g may occur. Comby reports a 
3 case with six relapses lasting 
- in all four months. They may 

1 occur about the time a nor- 
3 mal temperature has been 
tf reached; there is, however, 
g usually an intervening afebrile 
£ period of from five to ten days. 
a The relapse commonly runs a 
fg shorter and milder course and 
g is attended with little danger. 
g Complications. — Parotitis 
£ may occur during the second 

I. or third week and may result 
^ in abscess of the parotid 

2 gland; careful mouth disin- 
fection diminishes the fre- 
quency of this complication. 
Furunculosis, otitis media, 
pneumonia, deep-bone ab- 
scesses, arthritis and menin- 
gitis may occur, and a latent 
tuberculosis may become ac- 
tive. Within the last two 
years I have seen two cases of 



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PEOPHYLAXIS 275 

typhoid meningitis, both of which recovered. The symptoms of meningitis 
in both cases developed late in the disease, and typhoid bacilli were ob- 
tained in pure culture from the cerebrospinal fluid. 

Prognosis, — The prognosis of typhoid fever in children is much better 
than it is in adults. In 100 cases Blackader had only one death. Crozer 
Griffith reported a mortality of 3 per cent. These estimates, however, are 
much below the average mortality, which ranges in the neighborhood of 
6 per cent. In very young infants the mortality is great, from 20 to 40 per 
cent.; between two and ten it is low; in children over ten it gradually 
increases. 

Differential Diagnosis. — Paratyphoid fever very closely resembles mild 
typhoid fever, but from the standpoint of therapy there is no reason for 
attempting a differential diagnosis. In paratyphoid the Widal reaction 
is negative, but an agglutination reaction may be obtained by using para- 
typhoid cultures. Acute miliary tuberculosis is the disease most commonly 
mistaken for typhoid fever. It produces in the child a clinical picture 
closely resembling adult typhoid. In these cases, however, the absence of 
Widal reaction, the previous history of the child, the presence of other 
signs or symptoms of tuberculosis, the great irregularity of the temperature 
curve, the absence of rose-spots, the presence of leukocytosis and the pos- 
sible finding of tubercles in the choroid should suffice to make, the diag- 
nosis. If perchance doubt still exists, the diagnosis will be made later by 
the long-continued fever and the complicating tuberculous meningitis or 
tuberculous bronchopneumonia. Intestinal grippe may present a clinical 
picture which suggests typhoid fever, but the accompanying catarrhal 
symptoms with an absence of rose-spots, Widal reaction, diazo reaction and 
typical temperature curve should suffice to make the diagnosis. 

Prophylaxis. — The most important measure in prophylaxis is to use 
only uncontaminated water for drinking purposes, and the best safeguard 
in this direction is to be found in drinking boiled water. This precaution 
is necessary in most of our large cities, since the filtering systems in vogue 
are not an absolute protection against this disease. In country districts, 
when typhoid fever is epidemic, all well and spring water should be care- 
fully avoided or should be boiled before using. As milk is also a source 
of danger, it is on the whole safest to use only boiled or "clean" raw milk ; 
this is especially advisable during epidemics of typhoid fever. Oysters, 
known to come from beds contaminated with sewage, should be avoided. 
Vegetables and fruit, to be eaten raw, should be washed with boiled water. 
The feces and urine of typhoid fever patients should be received in a 1 
to 20 carbolic acid or a 1 to 1,000 bichlorid solution. All bed and per- 
sonal clothing of the typhoid fever patient should be soaked in the same 
carbolic acid solution for one or two hours and then boiled. The body of 
the patient should be cleansed following evacuation of the bowels. The 
nurse should exercise the greatest care in handling the excreta and cloth- 
ing of the patient, and should, after such handling, carefully disinfect her 
hands, for only in this way may she be sure that she will not infect herself 



276 TYPHOID FEVEE 

directly, or contaminate her food supply with the typhoid bacilli clinging 
to her hands. While it is not necessary to isolate or quarantine typhoid 
fever patients, it should be remembered that the interests of the patient 
and the safety of the household are best served by preventing all unnec- 
essary contact between the sick and the well. 

Nursing mothers with typhoid should wean their babies, not only for 
the protection of the infant, but for the welfare of the mother. 

Anti-typhoid inoculations with sterile typhoid cultures, as practiced by 
A. E. Wright in India, produce an increased temporary resistance to the 
typhoid infection. This prophylactic measure, however, is hardly justi- 
fiable except for the protection of hospital attendants or large bodies of 
people who are especially predisposed to this disease by camp life. 

Treatment. — Typhoid fever is a self-limited disease for which we have 
no specific medication. It can, however, be materially influenced in its 
severity and shortened in its course by careful attention to hygienic details 
and to proper dietetic and medical treatment. The patient should be put 
to bed, and remain there for at least one week after all acute symptoms 
have disappeared. The room which he occupies should be large and well 
ventilated. A comfortable bed should be provided with a smooth hair 
mattress resting on box springs, and a rubber cloth should protect the mat- 
tress underneath the sheet. Good nursing is all-important; the patient 
should always be under the watchful eye of a competent observer. In older 
children the bed-pan and urinal should be used and it should be the ob- 
ject of the nurse to tactfully keep the patient as quiet as possible, allow- 
ing him to do nothing for himself that can be done by others. With a 
young child it may be necessary to lift him out of bed and hold him tem- 
porarily in arms; this may relieve the nervous irritability and fretfulness. 
The hips and back of the patient should be rubbed once or twice a day 
with alcohol and the position of the body changed from time to time; this 
is necessary in severe cases to prevent the formation of bed sores. Care- 
ful records of pulse, temperature and respiration should be taken at reg- 
ular intervals and the nurse instructed as to the warning symptoms of 
hemorrhage and perforation, so that she may summon medical assistance 
at once if these symptoms occur. The mouth, throughout the disease, 
should be carefully cleansed three times a day with a mild alkaline anti- 
septic; this will greatly diminish the danger of parotid infection and 
prevent the dry and fissured tongue which comes from mouth contami- 
nation. 

Koutine Teeatment. — Diet. — The dietetic treatment is all-important. 
In the child, even more than in the adult, milk is the most important 
article of diet. In young children, however, it is advisable to combine it 
with a cereal gruel. If diarrhea occurs with curds in the stool, it is 
advisable to substitute skimmed milk for whole milk; if this does not 
correct the trouble the skimmed milk or the whole milk may be peptonized 
and combined with barley water. It is of the greatest importance that 
the intestinal discharges of the child be inspected from day to day, for the 



TREATMENT 277 

purpose of determining whether the food is undergoing abnormal fermenta- 
tion and thereby adding the symptoms of intestinal toxemia to those of 
typhoid; in this event the dietetic measures previously outlined for the 
treatment of acute diarrheal diseases are applicable. The "buttermilk 
mixture/' thick cereal decoctions, fresh meat juice and some of the pro- 
prietary meat preparations, such as liquid peptonoids, panopeptin, and 
Valentine's meat juice, are of value in many of these cases. The pro- 
prietary milk foods, such as malted milk and Nestle's food, may be used 
and flavored with cocoa to make them more palatable. It is most impor- 
tant that the child should not be fed too frequently or too much, but, if 
possible, a sufficient number of calories should be given to satisfy nutri- 
tional demands and prevent great loss of weight. Where the digestive 
capacity of the child, however, is such that it must necessarily be greatly 
underfed, then alcohol should be used not as a stimulant but as a food to 
make up the deficiency in calories. Alcohol may be given in the form of 
the proprietary meat preparations above mentioned or good whiskey and 
brandy well diluted may be used. For a child six years of age, two tea- 
spoonfuls of whiskey as a toddy or combined with carbonated water may 
be given every four hours; alcohol given under these conditions serves as 
a fuel for the cells of the body and prevents nitrogenous waste. As a part 
of the routine treatment the patient should be given plenty of water ; this 
flushes the excretory organs and diminishes the toxemia. During conva- 
lescence the same diet upon which the child has gone successfully through 
its illness should be continued for one week after the temperature has 
reached normal, then gradually soft-boiled eggs, milk-toast, scraped meat- 
ball, orange juice, bread, and other foods may be added. 

At the onset the patient should have a dose of calomel, followed by 
castor-oil or a saline cathartic. Dilute hydrochloric acid to older children 
and guaiacol carbonate and salol to young children may then be given as a 
matter of routine treatment. 

The bath is an important part of the routine treatment; it reduces the 
fever, makes the patient more comfortable, quiets his nervous system, pro- 
duces sleep, and acts as a general tonic. . The routine treatment of tub- 
bathing by Brand's method, which is of great value in the treatment of 
adult typhoid, is neither advisable nor necessary in the treatment of this 
disease in children; the shock and excitement produced by the cold bath 
more than counteracts its good effects. In ordinary cases a tepid bath 
with water containing alcohol, or the fan-bath, should be given three times a 
day. If the fever be high and the nervous symptoms marked, this bath, pro- 
longed for ten minutes, may be given with cool water and an ice-bag applied 
to the head. Where the nervous symptoms and high temperature are still 
more pronounced the patient may be given a cold pack by wrapping him in 
sheets wrung out of cold water and then covering him with a blanket; dur- 
ing this process the arms and legs should be rubbed to promote circulation. 
The character of the hydrotherapeutic measures used will largely depend 
upon the severity of the symptoms and the age and temperament of the 



278 TYPHOID FEVER 

child. Whatever measures are adopted should favorably influence the symp- 
toms and make the patient more comfortable. 

Symptomatic Treatment. — It is rarely necessary to use energetic 
measures for the control of the fever; the hydrotherapeutic measures above 
given usually answer every purpose. Beating down the temperature does 
not shorten or favorably influence the disease, and medical antipyretics are 
therefore not indicated. The coal-tar products, such as phenacetin and 
antipyrin, will do more harm than good if given for any length of time. 

The nervous symptoms can usually be controlled by hydrotherapy and 
an ice-bag to the head. The bromides may be of value in some cases. 
Opium in rare instances may be indicated in older children, but should be 
avoided if possible, as it aggravates the constipation and increases the in- 
testinal toxemia. Intestinal pain, when severe enough to demand treat- 
ment, is best relieved by paregoric. 

Constipation, which is the rule in younger children, can usually be over- 
come by enemata and suppositories; if, however, these do not suffice, laxa- 
tives should be used, such as milk of magnesia, castor-oil, and aromatic 
cascara. Much harm may be done by the constipation and resulting in- 
testinal toxemia, and the unfounded dread of laxatives not infrequently 
prolongs the disease many weeks. 

It should be remembered that the diarrhea of typhoid fever is for the 
most part salutary, and is nature's effort at elimination; if this symptom 
be not excessive it requires no treatment. From two to four loose stools in 
twenty-four hours is better than constipation; excessive diarrhea, however, 
should be controlled by subnitrate of bismuth in 5- to 10-grain doses, put 
up in simple chalk mixture. In aggravated cases it may be necessary to 
give paregoric, care, however, being taken that the diarrhea be not too 
suddenly controlled or converted into constipation. In every case of ex- 
cessive diarrhea the diet should be modified to suit the conditions; it may 
be necessary to discontinue milk for a few days and substitute for it broth, 
albumin water, meat juice, cereal decoctions, or whiskey. When the milk 
is resumed it may be skimmed, peptonized, or diluted with a cereal decoc- 
tion as the exigencies of the case demand. In short, a typhoid fever case 
with an aggravated diarrhea is to be fed as though we were dealing with an 
acute enteritis. If marked meteorism be present a soft rubber catheter 
introduced high into the colon, as recommended by Forchheimer, may be 
of value in carrying off gas and relieving the abdominal distention. 

Intestinal hemorrhage requires the same treatment as in the adult, viz., 
absolute quiet, the patient doing nothing that can be done for him by 
others; temporary abstinence from food, water and ice being allowed; a 
hypodermic injection of morphin, 1/30 of a grain for a child six years of 
age, to be repeated in six or eight hours, and the application of cold to the 
abdomen by ice-bags, a layer of flannel intervening. If the hemorrhage be 
great and collapse threatens, the patient should be stimulated by hypo- 
dermoclysis of normal salt solution and by the hypodermic use of tincture 
of strophanthus, 2 or 3 drops, well diluted, for a child six years of age. 



ETIOLOGY 279 

Intestinal perforation demands immediate surgical interference; when 
the physician suspects this condition surgical advice should be sought. 

May typhoid fever patients be sent home without additional risk? 
— This is often a question of the greatest importance and one that the 
physician is called upon to decide. In a typhoid fever epidemic which I 
studied in northern Michigan some ten or fifteen patients were sent to 
their homes in the first and second weeks of the disease. Some of these 
had a fourteen hours' railroad journey, others a twenty-four hours' journey 
by boat, and all of them reached their homes in safety and made satisfac- 
tory recoveries. One of these patients had a temperature of over 105° F. 
when she was carried to the train. With these particular cases it was a 
question of remaining in uncomfortable summer cottages through a long 
illness or of being treated at home under most satisfactory conditions. 
Under such circumstances there should be no hesitation in sending typhoid 
fever patients to their homes during the first week of the disease; this is 
especially true of children. Other things being equal, however, typhoid 
fever patients should be treated where they are taken ill, and above all 
should not be moved in the later stages of the disease. There is more 
danger in traveling during early convalescence than during the first week 
of the disease. 



CHAPTER XXXV 

MALAKIA 

Malaria is an acute infectious disease caused by the Plasmodium ma- 
laria?; it is characterized by more or less regular recurring intermittent or 
remittent symptoms, the most pronounced of which is fever. 

Etiology. — The sole cause is the plasmodium malariae, a hemacytozoon 
discovered by Laveran in 1880. This parasite is found in three forms, the 
tertian, the quartan, and the estivoautumnal ; of these the tertian is by far 
the most common and is present in the great majority of the cases. On 
first entering the red blood corpuscle it appears as a small mass of non- 
pigmented protoplasm. As it gradually increases in size it becomes more 
and more pigmented, and the hemoglobin is gradually destroyed until the 
corpuscle finally appears, much paler than normal, inclosing a pigmented 
mass almost filling the cell. This mass splits into segments which are dis- 
charged into the blood during the chill stage ; they subsequently enter other 
red corpuscles, where the same process is repeated. The full cycle of its 
development in the body is forty-eight hours, and this cycle represents the 
clinical manifestations of a malarial paroxysm, including the intervening 
quiescent period. In children, more commonly than in adults, there is a 
double infection by two sets of tertian parasites which mature on alternate 
days, thereby producing a paroxysm of acute symptoms every da}\ The 
two sets of parasites may or may not mature at the same hour on alter- 



280 MALARIA 

nate days, so that in these cases of double infection the acute symptoms, 
while they recur at practically the same hour every third day, may vary as 
to the time of the beginning of the paroxysms on alternate days. Another 
point of clinical importance is that the paroxysms caused by the two sets of 
parasites may markedly vary in their intensity ; a severe paroxysm occurring 
every third day and a mild paroxysm on the intervening days. The quartan 
parasite, which requires seventy-two hours, for its cycle of development, 
produces acute clinical manifestations every fourth day, and the estivoau- 
tumnal parasite, which is the cause of the irregular and more severe forms 
of malaria, may complete its cycle within twenty-four hours. This para- 
site is commonly found in the remittent malarial fevers, and while nothing 
like so common as the tertian parasite, is not infrequently found in the 
United States. The quartan parasite is rare. Malarial parasites as they 
occur in children present no peculiarities from the forms found in the 
adult. A detailed description of these various forms may be found in the 
text-books on practice. 

Infection. — The anopheles, a genus of mosquito, is the all-important 
agent by which the disease is transferred from man to man, and so far as 
we are aware this is the only means by which the disease is spread. The 
mosquito becomes infected with the malarial parasite by sucking the blood 
of a malarial patient ; it acts as the intermediate host for this parasite and 
in its body the life cycle of the plasmodium is completed. This requires 
about a week, and then large numbers of malarial sporozoids are excreted 
by the salivary glands and are transferred to man by the biting of the mos- 
quito. In the body of the individual thus inoculated by the infected mos- 
quito the parasites rapidly multiply, as previously described, until they 
are present in sufficient numbers to produce clinical symptoms. The time 
thus occupied in the body of their host before clinical symptoms are pro- 
duced is on the average fourteer days, and this represents the stage of 
incubation. 

In the middle and northern portions of the United States malaria is 
more prevalent in the late summer and early fall. It is more commonly 
seen in the southern and Atlantic coast states than in the north and west. 
It is more prevalent in the neighborhood of stagnant water and there is 
greater liability to contract it after sunset than during the day. All of 
these facts may be explained by the habits and habitats of the mosquito. 

Latency of Malaria. — This is one of the diseases characterized by latent 
stages; the parasite, once it has gained access to the human body, may re- 
main dormant or latent for long periods of time. The acute symptoms of 
the disease having been temporarily controlled and the patient having ap- 
parently made a satisfactory convalescence, a second attack of acute malaria 
may occur without a new infection. Eelapses more commonly occur when 
the individual harboring these latent parasites has a lowered resistance oc- 
casioned by disease, or other causes which diminish the vitality and pro- 
duce malnutrition, t^ius provoking second attacks of malaria even long 
after the patient has recovered from the primary attack. 



SYMPTOMATOLOGY 281 

Immunity. — One attack of malaria not only does not confer immunity, 
but predisposes the child to second attacks. Natural immunity is very 
rare. The negro, however, appears to be slightly less susceptible than the 
Caucasian. No age is immune. Infants, children, and adults are alike 
susceptible to this disease. It may even occur in liters and is perhaps not 
infrequently transmitted in this way from the mother to the child. Below 
is given the temperature chart of a case of congenital malaria. The mother, 
while pregnant with this infant, visited a malarious country and there con- 
tracted the disease. She suffered severely from tertian malaria during the 
last months of her pregnancy. The infant was born and lived in a section 
of country absolutely free from malaria, and when sixteen months of age 
it became violently ill with a gastroenteric infection. In the convalescence 
from this attack it developed a severe form of tertian malaria, the typical 
parasites appeared in the blood and the disease was controlled by quinin 
administered hypodermically. Crandall reported a case occurring eighteen 
hours after birth. Infant had distinct malarial paroxysms and the blood 
of both the mother and child contained malarial parasites. The general 
consensus of opinion is that infants are perhaps more susceptible but less 
exposed to inoculation by the malarial mosquito than adults. If fewer 
cases, therefore, occur among infants it is rather due to their protection 
from the mosquito than to the lack of their susceptibility. Loffler says 
that, "children are exclusively the carriers of the parasites in many dis- 
tricts in which malaria is endemic and that only the examination of the 
children will determine whether endemic malaria is present in a locality." 
This, he says, is an observation of Koch of great importance in the prophy- 
laxis of the disease. 

Symptomatology. — In children over eight or ten years of age the symp- 
tomatology is practically the same as that in adults. The periodicity of 
the symptom group is its chief characteristic. In the common form of 
malaria produced by the tertian parasite the paroxysm is usually an- 
nounced by a general feeling of discomfort, associated with headache, chilli- 
ness, and sometimes a pronounced rigor, with nausea and vomiting. With 
the onset of these symptoms the hands and feet are cold, the lips blue, and 
hot water bottles and extra bed covering are utilized to make the patient 
more comfortable. The temperature rises rapidly and may reach 104° or 
105° F. within two hours; the headache grows worse, the body chill grad- 
ually disappears, the patient becomes hot and thirsty, asks for water, and 
throws off the heavy covering that has been used in the stage of rigor. 
Soon after the temperature reaches its height it begins to fall, but not quite 
as rapidly as it rose. It may reach normal, or even below, in the course 
of a few hours, so that the duration of the fever may vary in individual 
cases from one to twelve hours ; it commonly runs its course in four or five 
hours. "With the fall in the temperature a profuse perspiration may occur ; 
this symptom, however, is not so pronounced in the child as in the adult. 
As the temperature reaches normal the headache and other disagreeable 
symptoms disappear and the patient is in a condition of comparative com- 



282 



MALAEIA 



fort. The contrast between the great suffering which occurs during the 
height of the malarial paroxysm and the freedom from uncomfortable 



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Fig. 46. — Congenital Malaria; Child One Year of Age. 

symptoms which marks the interval between paroxysms is very great. The 
paroxysms of malaria produced by the tertian parasite commonly occur 



SYMPTOMATOLOGY 283 

every day, producing the quotidian rather than the tertian type of temper- 
ature. The daily paroxysms being due to a double infection by two sets of 
tertian parasites which mature on alternate days, thus producing a well- 
marked daily intermittent fever. The maximum temperature being 
reached at the same hour on alternate days, but perhaps varying from this 
hour somewhat on the intervening days. If the child be infected by only 
one set of tertian parasites a typical tertian intermittent fever is present; 
the paroxysm of fever, with its accompanying symptoms, occurring every 
third day and reaching its maximum about the same hour; on the inter- 
vening day the child is comparatively comfortable. The quartan parasite, 
which is rarely seen in the United States, produces an intermittent fever, 
the paroxysms of which occur about the same hour every fourth day. In 
the two intervening days the patient is comparatively comfortable. The 
estivoautumnal -parasite produces an irregular type of fever commonly re- 
mittent or very irregularly intermittent. In this type of malaria great 
variations in the temperature may occur from hour to hour and only fre- 
quent temperature records can keep track of the excursions which the tem- 
perature may make, but on the whole, in this form of malaria, the tem- 
perature may be considered as belonging to the continuous remittent type 
rather than to the intermittent type. 

Spleen. — In all forms of malaria the spleen is notably enlarged and can 
easily be palpated. In the typically remittent tertian form it may increase 
in size during the paroxysms. In chronic forms of malaria the enlarge- 
ment of the spleen is very great and is an important diagnostic feature. 
The liver is also commonly enlarged. 

Anemia. — Acute malaria produces a well-marked anemia which in ag- 
gravated and chronic cases may cause the characteristic malarial cachexia 
in which the skin has a pale yellow color. The enormously enlarged spleen 
which is associated with this cachectic condition may suggest the possibil- 
ity of some form of severe primary anemia. A blood examination of these 
cases, however, shows no leukocytosis and reveals the existence of a pro- 
found secondary anemia, which is marked by a great diminution of both 
red blood corpuscles and hemoglobin. This secondary anemia sometimes 
resembles the chlorotic type. 

Intermittent neuralgia is one of the common manifestations of sub- 
acute or chronic malaria in older children. The supraorbital nerve is a 
favorite site for this pain, but almost any nerve in the body may be af- 
fected. The paroxysm recurs at about the same hour every day or every 
second day, but is not necessarily accompanied by fever. The periodicity, 
however, of a neuralgia by no means classes it as malarial, since neuralgia 
from other causes may return at more or less regular intervals. Intermit- 
tent spasmodic torticollis occurring at the same time every day, or every 
second day, is a malarial manifestation rather more common in the child 
than it is in the adult. 

Peculiarities of Malaria in the Infant. — From the above clinical syn- 
drome of malaria, as it occurs in the child, there may be variations in in- 



284 MALARIA 

fancy. At this period the chill is absent and for it a condition of drowsi- 
ness, cold hands and feet, with marked prostration, may be substituted. 
Convulsions occasionally occur. Vomiting very commonly marks the onset 
of the paroxysm and nausea may continue until the fever begins to subside. 
The onset of acute symptoms is usually more abrupt in the infant and the 
paroxysm is sometimes associated with an acute pulmonary congestion 
which may suggest the onset of pneumonia. 

Diagnosis. — The diagnosis is positively made by finding in the blood 
the plasmodium malaria?; this is not always a simple matter. A number of 
blood examinations are not infrequently required before the plasmodium is 
discovered. The blood for these examinations should be obtained shortly 
before the onset of the malarial paroxysm, when the red blood corpuscles 
contain the pigmented parasite. This examination should also be made 
before quinin is given. 

Pronounced simple anemia with an enlarged spleen and regularly re- 
curring paroxysms of fever and no leukocytosis suggests the probability of 
malaria. If under these conditions an examination for the plasmodium be 
not practicable the diagnosis may be confirmed by the specific action which 
quinin has on these symptoms. In tuberculosis, pyemia, septicemia, pye- 
litis, and other conditions we may have intermittent paroxysms of chills 
and fever closely resembling irregular forms of malaria. But in these 
conditions the plasmodium is not found in the blood and the symptoms are 
not specifically influenced by the giving of quinin. Probably the most 
common source of diagnostic error lies in the remittent forms of malaria, 
which may be mistaken for typhoid or some other continuous fever. 

Treatment. — Prophylaxis may best be accomplished: First, by the 
destruction of the malarial mosquito (anopheles). This may be accom- 
plished by fumigating infected houses with sulphur; destroying the breed- 
ing places of the mosquitoes by draining stagnant pools and killing the 
young anopheles by pouring crude petroleum over all stagnant water that 
cannot be drained. Second, by preventing man from being bitten by the 
infected mosquito. This may be done by the use of house screens and 
mosquito netting to cover the beds. Third, by the prompt and effective 
treatment of all malarial cases in the neighborhood so as to prevent the 
anopheles becoming infected. Fourth, by good food and proper hygiene 
for increasing the resisting power of the individual. 

Medical Treatment. — Quinin is a specific for malaria, When it 
reaches the blood it rapidly destroys the malarial parasites and quickly 
terminates the symptoms of this disease. 

Method of Administration of Quinin. — In older children the sulphate 
may be given in capsules. Pills are not to be used, since they may pass 
through the intestinal canal without being dissolved. In younger children 
the bimuriate or bisulphate of quinin is preferable; the solubility of these 
preparations promotes their absorption and thereby adds greatly to their 
efficacy. I have seen young children suffering from malaria who refused 
to yield to the sulphate and the various so-called tasteless preparations of 



TREATMENT 285 

quinin, who promptly responded to the bisulphate given in solution or to 

hypodermic injections of quinin urea hydrochlorate. The following pre- 
scriptions are recommended : 

J£ Quinin bimuriati 3 ss J$ Quinin bisulphat 3 S s 

Sodii chloridi grs> v Acidi tartaric grs . xv 

Aquae destilatae § ii Aquae destilatae 5 ii 



J^ Quinin urea hydrochlor. 3 ss 
Aquas destilatae §■ {{ 

The great difficulty that attaches to the administration of quinin in 
children is its very disagreeable taste. Where it is possible it is better to 
administer the quinin in aqueous solution, as in this form there is less pos- 
sibility that it may disturb the stomach and produce vomiting. With young 
children a dose of the above solution may be mixed at the time of giving 
with a small quantity of syrup of licorice or elixir of yerba santa to cover 
the disagreeable taste of the quinin. Euquinin in double the dosage of 
other quinin preparations may be given to infants, as it is comparatively 
tasteless and does not irritate the stomach. The insoluble tannate of 
quinin put up in the form of quinin chocolates is of little or no value. It 
is always desirable to administer quinin by the mouth where this is possible ; 
but an irritable stomach or failure in assimilation may make it necessary to 
give quinin in some other way. Under such conditions it should be used 
hypodermically, and the above solutions of bimuriate, bisulphate, and quinin 
urea hydrochlorate, when properly sterilized, may be administered in this 
manner. With the latter preparation I have had considerable experience. 
All of these are more or less irritating when given hypodermically, but the 
urea hydrochlorate is perhaps less so. Each injection is followed by a 
well-marked induration of the subcutaneous tissues which subsides in a 
few days. The hypodermic treatment of malaria does not, as a rule, have 
to be continued longer than three days. By this time the malarial par- 
oxysms will have come under control, the nausea and vomiting will have 
disappeared, and quinin may again be administered by the mouth. It may 
also be administered by rectum; for this purpose the above solutions are 
available. They should, however, be largely diluted six or eight times with 
a dextrinized cereal decoction or with a thin starch water. There is no 
question but that absorption may take place when the drug is given in this 
manner, but the amount of absorption is uncertain and the method is far 
from reliable. I have little faith in suppositories of quinin and believe 
that they are comparatively useless. Quinin cannot be given by inunction ; 
the drug is not absorbed through the skin. I have demonstrated this fact 
to my own satisfaction by careful experimentation. 

Dose of Quinin. — At one year of age, two grains every four hours ; at 
two years of age, four grains; at four years of age, six grains; at six years 
of age, eight grains; increasing one grain for every year of life thereafter. 
For hypodermic use the dose should be one-half, and for rectal use twice 
the size above given. 



286 MALARIA 

Time of Administration. — To the infant and child it is best to give 
quinin at regular intervals throughout the twenty-four hours when not 
asleep. The doses above recommended may be given at two- to four-hour 
intervals. When quinin is used hypodermically it should be given in rather 
large doses about three hours before the beginning of acute symptoms. In 
the older child large doses of quinin should be given four hours before the 
beginning of the expected paroxysm. 

Apart from the quinin treatment, the management of a case of acute 
malaria must be purely symptomatic. During the chill the patient may be 
warmed with hot-water bottles and additional covering. Phenacetin and 
antipyrin in suitable doses may be given just before or at the beginning of 
the paroxysm to relieve the headache and make the patient more comfort- 
able. After the fever rises and the chill disappears, an ice-bag to the head 
or sponging the body with cool or lukewarm water may be grateful to the 
patient. If constipation exists a cathartic should be given in the interval 
between paroxysms. A good-sized dose of calomel answers this purpose, 
and by many observers is believed to promote the absorption of quinin. The 
diet during the acute stage should be carefully selected to protect the 
stomach and prepare it for quinin medication. During convalescence the 
food should be selected with reference to the digestive capacity and nutri- 
tional demands of the child. 

Arsenic is a very valuable remedy in convalescence from acute malaria. 
It acts as a blood tonic and prevents relapses. In the treatment of the 
chronic forms of malaria, especially those associated with enlarged spleen, 
malarial cachexia, and neuralgias, arsenic is of almost as much value as 
quinin. To young children it may be administered in the form of Fowler's 
solution; to older children arsenious acid may be given. Fowler's solu- 
tion should be given in some palatable vehicle, such as essence of pepsin, 
one minim three times a day for a child two years of age and three minims 
for a six-year-old child. Arsenic should be administered with slight in- 
terruptions for a period of two months and during a portion of this time 
should be combined with some of the organic iron preparations. In younger 
children Fowler's solution may be combined with one of the malt and 
organic iron preparations. This combination is effective and palatable. In 
children from twelve to fourteen years of age the following prescription is 
of value : 

J^ Acidi arseniosi % gr. 

Ferri reducti 20 grs. 

Quinise sulph 30 grs. 

20 capsules put up dry. 
Sig. One after eating. 



AGE 287 



CHAPTER XXXVI 

WHOOPING-COUGH 
(Pertussis) 

Whooping-cough is an acute infections disease characterized by a more 
or less violent spasmodic cough, recurring in paroxysms, accompanied by 
the expulsion of mucus and commonly by vomiting. The paroxysm of 
coughing is interrupted or terminated by an inspiratory crow or whoop, 
which gives the name to the disease. 

Etiology. — The "bacillus pertussis 7 ' of Bordet and Genou is possibly 
the specific cause of this disease. These observers isolated this micro- 
organism from the pharyngeal mucus, and Wollstein observed that it re- 
acted positively to agglutination tests with the blood of the convalescent 
patient. At the present time, however, all that one can positively say is 
that whooping-cough is caused by a microorganism whose favorite habitat is 
the pharynx, larynx, trachea, and bronchi, and that the common exciting 
cause of the cough paroxysm is a plug of laryngeal or bronchial mucus. 
The infectious principle of whooping-cough multiplies rapidly in its human 
host, and is also capable of affecting dogs and cats. It is not, however, 
known to multiply outside the bodies of its hosts, but it may live for as long 
as ten days or two weeks in the dried state. It is thrown out by breathing, 
coughing, or sneezing; the mucus thus expelled may carry the contagion 
to all parts of the room and may deposit it on the clothing of the doctor or 
attendant, who in turn may carry it to a third party; indirect contagion, 
however, is, according to Morse, a very rare occurrence. The disease is 
usually communicated by the well coming in close intercourse with the sick, 
in homes, at schools, children's parties, and other public gatherings. There 
are unusual opportunities for the sick coming in contact with the well and 
thus spreading this disease, since during the catarrhal stage, when it is 
most infectious, the diagnosis is not usually made and the child is not ill 
enough to prevent its mingling with other children in the usual pursuits of 
life. Quarantine regulations are, therefore, ineffectual in preventing the 
spread of whooping-cough, which is endemic in all of our cities and which 
becomes more or less epidemic every two or three years. Epidemics occur 
throughout the year; cold weather, however, increases the number of cases 
and the frequency of complications. There is great variability in the viru- 
lency of different epidemics; the disease may prevail in either a mild or a 
severe form. 

Age.- — The majority of exposed individuals contract whooping-cough, 
but susceptibility is not so general in this disease as it is in measles. Nurs- 
ing infants under six months of age are comparatively immune; the dis- 
ease, however, may occur even in the new-born. It is most common from 
the end of the first to the beginning of the fifth year of life. Fifty per 
20 



288 WHOOPING-COUGH 

cent, of the cases occur under two years of age, so that the second year of 
life is by far the most susceptible period. After the fourth year there is a 
gradually diminishing susceptibility. Old age is not exempt; I knew a 
physician who at the age of sixty-five contracted whooping-cough after 
having been repeatedly exposed over a period of thirty-five years to the 
contagion of the disease. 

Neurotic children are perhaps not more susceptible, but they have this 
disease in a more severe form. Tuberculous children also have whooping- 
cough very severely ; the disease aggravates the lymph-node tuberculosis, and 
the tuberculosis, on the other hand, by enlarging bronchial lymph nodes, 
causes pressure on the laryngeal nerves, which may prolong the spasmodic 
stage of whooping-cough for many months. 

Period of Contagion. — The catarrhal stage of whooping-cough is very 
much the most infectious and it is especially during this period that the 
disease is spread. It is, however, also contagious during the spasmodic 
stage, and I have been much impressed with the fact that the contagion 
largely disappears very early in this stage. I have again and again seen 
children during this period of the disease brought into contact with 
other children in their outdoor play without spreading the infection. A 
quarantine lasting longer than five weeks is unnecessary. Second at- 
tacks of whooping-cough are extremely rare. The immunity con- 
ferred by an attack is as safe and as lasting as it is in any other contagious 
disease. 

Incubation. — This period is rather uncertain; it probably lasts from 
six to ten days. Cases are reported where the catarrhal symptoms have 
begun within the first thirty-six hours after exposure. 

Symptomatology. — The symptoms are divided into three stages, the 
catarrhal, the spasmodic, and the convalescent. 

Catarrhal Stage. — The catarrhal stage begins with bronchitis, pharyn- 
gitis, and rhinitis; the pharynx, nose, throat, and eyes are usually con- 
gested. The cough is the most important symptom; it soon becomes very 
irritating and harsh and is associated with the physical signs of an ordinary 
bronchitis of the larger tubes ; it is, however, more irritating and harassing 
than the cough of ordinary bronchitis and is worse at night ; in the begin- 
ning it is not, as a rule, paroxysmal, but it is so hard and persistent that 
the child's face becomes congested. In infants the cough may become 
paroxysmal during the first two or three days of the disease. In older 
children the duration of the catarrhal stage differs greatly, but usually 
during the second week the cough, which has continued to grow worse, be- 
comes more paroxysmal, and the typical cough of the spasmodic stage grad- 
ually develops. There is a slight rise of temperature, 101° to 102° F., 
accompanied by headache and general nervous irritability. With the 
change in the character of the cough the fever and catarrhal symptoms 
subside, and the general condition of the child improves. 

Spasmodic Stage. — This begins at the end of the first or second week 
and is characterized by a more or less violent spasmodic cough, which re- 



SYMPTOMATOLOGY 289 

curs in paroxysms and is commonly interrupted or ended by an inspiratory 
whoop; mucus is expelled and vomiting frequently occurs. The cough, 
during this stage, recurs in distinct paroxysms, with longer or shorter in- 
tervals of rest, and the child, notified of the approach of the cough by 
pharyngeal irritation, places itself in a position to withstand the approach- 
ing attack. The cough is violently explosive in its character and the ex- 
plosive expirations come in such rapid succession that after a time respira- 
tion almost or entirely ceases; this is followed by a loud sighing, whooping 
inspiration, accompanied, as a rule, by the expulsion of a mass of frothy 
mucus or by vomiting. If the mucus plug is not removed from the larynx 
the attack may be immediately repeated and followed by general exhaustion 
and muscular relaxation. During the paroxysm the child's tongue pro- 
trudes ; its face becomes red, then a darker hue, and, in some cases, almost 
blue or cyanotic; its eyes bulge, the conjunctival mucous membranes are 
congested, and the whole body is in a state of muscular and nervous tension 
which is aggravated by the sense of impending danger which these attacks 
inspire. The above description represents a severe paroxysm of whooping- 
cough. These attacks may be much milder or they may be more severe and 
complicated with convulsions and other profound nervous symptoms. More 
or less emphysema occurs in nearly every severe case ; it is especially marked 
in the apices of the lungs and in rare instances the lung may rupture, 
producing pneumothorax or a subcutaneous emphysema. Nose-bleed and 
conjunctival hemorrhages frequently occur; the latter produce the blood- 
shot eye so commonly seen in whooping-cough. Hemorrhages may also oc- 
cur from the throat, the bronchi, and the ear ; in rare instances the ear- 
drum may be ruptured. Incontinence of urine and of feces, especially in 
young children, may occur during the attack. A grayish-white ulcer may 
develop on the frenum of the tongue from injury to and subsequent infec- 
tion of this organ. Hernia and prolapse of the rectum may result from 
increased abdominal pressure. Attacks may be brought on by fits of anger, 
excitement, and violent exercise. They may vary in duration from one 
to fifteen minutes, depending upon their severity. The duration of the 
spasmodic stage may vary from two weeks to two months. Enlargement of 
the bronchial lymph nodes from a complicating tuberculosis may prolong 
the paroxysmal cough for many months. Attacks of influenza and bron- 
chitis may bring back the paroxysmal cough months after the child is ap- 
parently convalescent. This recurrence is strongly suggestive of bronchial 
lymph-node tuberculosis. 

During the convalescent stage, which lasts two or three weeks, all 
the acute symptoms rapidly subside. The bronchitis ceases, the character- 
istic cough loses its whoop, becomes much milder, less paroxysmal, and 
gradually disappears. 

Blood. — In whooping-cough the lymph nodes are everywhere enlarged, 
especially in the neck and peribronchial region. To correspond with this 
lymphatic irritation there is a well-marked leukocytosis, varying from 
20,000 to 40,000 ; all forms are increased, but the lymphocytes are especially 



290 



WHOOPIXG-COITrH 



so. The lymphocytosis is both relative and absolute and begins before and 
continues through the paroxysmal stage. 

Ukine. — Slight albuminuria may occur, but acute nephritis is a rare 
complication. The urine may contain sugar and an excess of uric acid. 

Course. — Whooping-cough is a self-limited disease running its course 
on the average in from six to eight weeks. The whooping-cough paroxysms, 
however, may be continued much beyond this period from enlargement of 
the bronchial lymph nodes. The lymph node enlargement in these cases 
is commonly tuberculous. In all cases in which the whooping-cough par- 
oxysms continue beyond the eighth week tuberculosis should be suspected, 
and the treatment should be the same as elsewhere given for lymph node 
tuberculosis. 

Complications. —Bronchopneumonia is the most serious of all the com- 
plications and is more frequent and more dangerous in infancy than in 



0F month 4 5 6 7 8 9 10 II 12 13 14 I5J 16 17 18 19 2021,22 23 24 25 26 27 28 29 30 1 


of disease 1 2 3 4 5 6 7 8 9 10 II 12 13 14 15 16 17 18 i 19; 20; 21 22 23 24 25 26 27 28 


107- 


105" ._ ._ 




* = AaAi a 


- - [ a i AWL r-MA. A 


* I- iMa h V \\k i \a * 


s - V MA ' M' 1 iN :|: W ■■"' 


l '" / v\l / - M/ A\/ r. 


* ° 3 V i / » / v v . ■=■ 


< 3° ! ' 1 ' A) 


- - r - ■ ' 


1 ' 



Fig. 47. — Pertussis axd Measles Complicated by Bronchopneumonia. 



childhood. It is produced by streptococci, staphylococci, and pneumococci, 
and occurs much more frequently during the winter months; it is more 
commonly seen in hospitals and tenement houses than in well-appointed 
homes. Enterocolitis is a much dreaded complication of whooping-cough 
in infants during the hot months and is responsible for no small part of 
the mortality of this disease. Tuberculosis is a common complication. A 
latent or slightly active lymph-node or pulmonary tuberculosis may be 
greatly aggravated into serious or even fatal forms of tuberculosis. Cardiac 
dilatation and weakened heart muscle are common complications and se- 
quels of severe whooping-cough : they are manifested by shortness of breath 
and by an irritable and rapid pulse which is easily accelerated by exercise. 
Many months may be required for the heart muscle to regain its normal 
tone. Measles, diphtheria, and scarlet-fever may. especially in hospital 
practice, occur as complications of whooping-cough and add much to the 
gravity of the prognosis. 

Diagnosis.— The diagnosis in the catarrhal stage is very difficult and, in 



TREATMENT 291 

the great majority of instances, the true character of the disease is over- 
looked until the characteristic paroxysmal cough develops. When the dis- 
ease is epidemic, or when it occurs during the summer months, its presence 
may be suspected early and a blood examination may confirm the diagnosis. 
Enlarged bronchial lymph nodes may produce a symptom group resembling 
whooping-cough. This condition is nearly always tuberculous, and may be 
differentiated by its chronic character and by the signs and symptoms of 
bronchial lymph-node tuberculosis. Adenoid vegetations may cause a 
paroxysmal cough, which is, however, not usually associated with the 
whoop and the after vomiting and is not aggravated at night. 

Prognosis. — The younger the child the more dangerous the disease. 
Under one year of age the mortality is great and during the second year it 
continues high; after that it gradually diminishes, so that in private prac- 
tice the disease is attended with little danger in children over four years 
of age. The mortality is greater during the winter months, when chil- 
dren are housed and ventilation is bad, and is due largely to broncho- 
pneumonia and tuberculosis. The death rate of whooping-cough is greatly 
increased among the poor during the summer months by a complicating 
enterocolitis. W. W Johnston called attention to the fact that statistics 
showed that more children died from whooping-cough in the United States 
than from scarlet-fever, and he estimated that 100,000 children die from it 
in every decade. Statistics in European countries also show that whoop- 
ing-cough is scarcely second to any of the ordinary acute infections in its 
mortality records, and yet this disease is treated lightly and is little 
dreaded by the laity. 

Prophylaxis. — A child with whooping-cough should be carefully 
isolated from other children, especially during the catarrhal stage. Abso- 
lute isolation during the paroxysmal stage is not consistent with the best 
forms of treatment, and is not in the vast majority of instances practicable. 
The greatest possible effort, however, should be made by the physician to 
protect children under three years of age, and tuberculous children of all 
ages, from coming in contact with the contagion of whooping-cough. It 
may be possible for the well to occupy the same playgrounds with whoop- 
ing-cough patients who are in the late paroxysmal stage of this disease, 
provided this is done under proper supervision, but well children should 
not be allowed to enter a room that has been occupied by a whooping- 
cough patient until that room has been thoroughly disinfected. 

Treatment. — The hygienic treatment of this disease is most impor- 
tant. The number of paroxysms of whooping-cough will depend largely 
upon the contamination of the air in which the patient lives. If kept in- 
doors in ill-ventilated apartments, breathing bad air contaminated with 
dust, germs, and carbonic acid, the paroxysms of whooping-cough will be 
greatly increased in number, aggravated in severity, and the pulmonary 
and intestinal complications will be more frequent. The most important 
part of the treatment, therefore, is to furnish the patient with the purest 
air possible, both by day and by night. During the spring, summer, and 



292 WHOOPING-COUGH 

fall months it is a comparatively easy matter to keep the patient out of 
doors a great portion of the time without causing excessive fatigue. Dur- 
ing the winter months the child should, on good days, spend a portion of 
the time out of doors and while indoors should live, day and night, in 
well-ventilated rooms. Where there is a family history of tuberculosis it 
is advisable to seek a milder climate for whooping-cough patients during 
the winter months. 

Children old enough to lead an active life should be carefully restricted 
as to exercise during the severe paroxysmal stage. Over-exertion in- 
creases the number of paroxysms of cough and throws an unnecessary strain 
upon a heart that is already weakened by disease. It is rarely necessary, 
except in severe complications, to forbid all exercise by confining the pa- 
tient to bed. 

Dietetic Treatment. — During the hot summer months all infants 
under two years of age suffering from whooping-cough should, from the 
\( j ry beginning of the disease, be most carefully dieted, to prevent the de- 
velopment of that much-dreaded complication, gastrointestinal catarrh. 
They should be removed from the city and sent to a place where they can 
get good pure air. If they are not breast-fed, the artificial food formula 
upon which they were living before the development of the whooping- 
cough should be reduced in strength and in quantity; infants, for ex- 
ample, nine months of age, who have been taking nine or ten ounces of food 
(, j \cvx four hours, should be given five or six ounces every three hours, and 
the percentage of milk in the formula diminished. If intestinal trouble 
develops, then every attention should be directed to its correction before 
it becomes a gastrointestinal catarrh; it may be necessary to peptonize 
the milk or to substitute skimmed milk for whole milk in the food formula. 
At any rate the physician should be impressed with the importance of 
using prompt dietetic and therapeutic measures for preventing entero- 
colitis in young infants suffering from whooping-cough. Careful and skil- 
ful feeding is required to maintain the general nutrition in children of all 
ages suffering from severe attacks of whooping-cough. Throughout the 
disease the child's diet should be carefully scrutinized, giving to it only 
such foods as fall easily within the range of its digestive capacity, and, 
since a full meal is one of the common reflex causes of the whooping- 
cough paroxysm, it is advisable that the child should be fed in smaller 
quantities at shorter intervals. Beef-teas and highly seasoned foods which 
may cause pharyngeal irritation and thus excite the cough are to he 
avoided. Jn severe cases where vomiting follows the taking of food the 
patient should again he fed within half an hour. Food taken ten or twenty 
minutes after a paroxysm of whooping-cough, whether that paroxysm be 
accompanied by vomiting or not, is usually retained, so that the best time 
to feed the child in severe cases is very soon or directly after a paroxysm. 
In rare instances ii may he necessary to give nutrient enemata of some 
of the soluble meal preparations or of peptonized milk. 

Psychic Treatment. — The psychic treatment of whooping-cough is of 



TREATMENT ' 

importance in children that are old enough to be thus i nfl uenced: this is 
especially true of neurotic children. They should be shielded from ex- 
citement, should be taught to control their temper and. most of all. should 
be impressed with the necessity of trying to postpone or control whoop- 
ing-cough paroxysms. 

Kilmer and others have recommended a snugly fitting abdominal elas- 
tic belt surrounding the body several inches above and below the region of 
the diaphragm. This elastic bandage is applied over, and attached to a 
much wider stockinet band which is held in position above by shoulder 
straps. Soner recommends that traction be applied in such a way as to 
pull both angles of the jaw forward and downward. It is believed that 
T_ir ; r devices modi: the severity of The cough and diminish the frequency 
of the vomiting. 

aLedical Treatment. — At The present Time The local treatment of the 
pharynx is not in vogue. The literature of whooping-cough is full of ad- 
vice on this subject, the details of which need not be repeated here. For- 
malin and cresolin vapors, made by lamps prepared for this purpose, may 
be used to disinfect the room. These vapors may exert a favorable influence 
on the whooping-cough paroxysm, but should never be used at the ex ense 
of fresh air. During winter months, in damp northern climates, where the 
paTiem is necessarily confined To his room for the greaTer portion of The 
Twenty-four hours, and where venTilation is limited To The partial opening 
of a window, or where fresh air is obTained by removing The patienT from 
room to room about the house, both cresolin and formalin vapors may 
nsed to advantage in disinfecting The air thaT The patient breathes. Oil 
of eucalyptus, carbolic acid, and creosote in vapor form are also recom- 
mended as room purifiers. 

:nin inTernally is The mosT valuable remedy we have in The treatmenT 
of whooping-cough. The patient may have an idiosyncrasy which prevenTs 
The administration of quinin. and in young children, especially in infants. 
iT should be carefully given so as not : listurb The ligestive organs. 
This is true of every drug which is administered to modify or control The 
paroxysms. Whooping-cough is a self-limked disease for which we have 
no specific medication _. and in which it is a very easy matter to do more 
harm Than good by The administration of drugs which disturb The gastro- 
intestinal organs, weaken The heart, tighten the cough and preven: 
expectoration. A drug. Therefore. ThaT is of real value, such as quinin. 
should be properly used and noT abused. In children old enough to I 
: suleSj The sulphaTe of quinin should be given in from 3- : 5-g 
loses Three times a day. In younger children euquinin should be used: 
This may be given in 2 -grain doses at two years of age. and 3-grain 1 - - 
at three years of age. I am a firm believer in the efficacy of the quinin 
treatment of whooping-cough and employ it in all cases where it is 
from The beginning to The end of The disease. 

As a routine TreatmenT belladonna in some form may be admin - 
Jacobi. for many years, has believed This drug To be our mosT valuable rem- 



294 WHOOPING-COUGH 

edy. It is best given in the form of the tincture, in doses of from 1 to 
3 minims, depending upon the age of the child, and should be repeated 
three or four times in twenty-four hours. If the severe paroxysms are not 
in any way modified, the dose is to be slightly increased day by day, until 
its physiological effects are shown in the dilated pupils or the flushed face. 
Bromid of potash is a valuable remedy for modifying the paroxysms. For 
a child two years of age the dose should be 3 grains every four hours, 
increasing it 1 grain for every year of life. The bromid of potash and the 
belladonna may be combined in the same prescription. In whooping-cough, 
more than in almost any other disease, medicines should be given only 
when they are positively indicated, but in cases requiring treatment the 
ordinary routine should be quinin three times a day, and bromid of potash 
with tincture of belladonna in a proper vehicle four times a day. Anti- 
pyrin, in from 1 to 4-grain doses, to suit the age of the child, has a marked 
influence in relieving the paroxysmal cough, but its depressing action 
on the heart demands that it should be used judiciously and for only a 
short period of time. Chloral hydrate is an hypnotic of some value in 
severe cases; it should be given in from 2 to 5-grain doses at four o'clock 
in the afternoon and at bedtime. The opium preparations may be recom- 
mended in older children for the control of the paroxysmal cough. Of 
these, paregoric (10 to 20 drops), sulphate of codein (1/50 to 1/8 grain), 
heroin hydrochlorate (1/100 to 1/20 of a grain) and bimecinate of mor- 
phin (% to 1 gtt) are the most valuable. These preparations, however, 
have no field of usefulness in the treatment of whooping-cough in children 
under two years of age. A record of the number of paroxysms occurring 
in twenty-four hours should be kept as an indication of the value of any 
form of treatment. Tincture of strophanthus and tincture of digitalis may 
be indicated in those cases where the pulse is weak and the heart muscles 
dilated. The vaccine treatment of whooping-cough has not been notably 
successful. When whooping-cough occurs in a child in whom there is a 
suspicion of latent tuberculosis, the child should be actively treated for the 
latter disease, as outlined under the Treatment of Glandular Tuberculosis. 
Pneumonia, the most dreaded complication, is to be watched for and treated 
on the appearance of its earliest symptoms. If one makes the mistake of 
beginning the treatment for tuberculosis or pneumonia when these compli- 
cations are not present, no harm is done, while, on the other hand, the 
patient's life may be lost by beginning the treatment too late. 



ETIOLOGY 295 

CHAPTEE XXXVII 

DIPHTHERIA 

Diphtheria is an acute infectious disease produced by the Klebs-Loffler 
bacillus. It manifests itself by the development and growth of a grayish- 
white membrane, usually located in the throat and air passages. In 
these foci the bacilli manufacture a very potent constitutional poison, the 
absorption of which is responsible for the toxic symptoms of this disease. 

Etiology. — The Klebs-Loffler bacillus, which is the specific etiological 
factor in every case of diphtheria, is rod-shaped, from 2 to 4 /i in length 
and from 0.4 to 0.8 jut in width. It may be straight or slightly curved and 
clubbed at the ends. It grows readily in common culture media, but best 
on Loffler's blood serum, showing within twelve hours a grayish-white 
growth. It is non-motile, aerobic and does not liquefy the blood serum. It 
grows most rapidly at the temperature of the body, in a neutral or slightly 
alkaline media; acids and strong alkalies inhibit its growth. It is grad- 
ually destroyed by the action of sunlight and quickly killed by a tempera- 
ture of 136 °F. Cold inhibits, but does not kill it. It may live for months 
in a dried state in clothing, bedding and carpets, and the disease may be 
spread by the belongings of the sick room and the clothing of the attend- 
ants. It is not uncommonly found in the throats of healthy individuals, 
who may act as carriers of the disease to others with more susceptible 
mucous membranes. In milk it lives and multiplies slowly, and epidemics 
may be produced in this way. W. H. Park found that guinea-pigs, chick- 
ens, birds, cats, rabbits, dogs, cattle and horses were susceptible to this 
disease. 

Human intercourse is the great cause of its spread. The contagion 
lies in the discharges which come from the local foci, usually located in 
the throat and nose. This bacillus is not readily carried through the air, 
and closer contact with the sick is necessary for the spread of this disease 
than for many other contagions, such as measles, small-pox and scarlet 
fever. Crowded tenements, schools and children's parties, which bring into 
intercourse the sick with the well, are important factors in the spread of 
diphtheria, since the carriers of this infection are very common among those 
who are apparently well. 

Diphtheria is rare in young and nursing infants. This immunity is 
probably due to immune bodies derived from the placental blood and is con- 
tinued by nursing milk from the breast of an immune mother. It is most 
common between the second and sixth year of life; after this, susceptibil- 
ity gradually diminishes, until in the adult it is comparatively rare. One 
attack confers immunity, but this is temporary and may last but a few 
months. Second attacks following rather closely upon the previous attack 
are comparatively mild. Catarrhal conditions of the throat and nose and 
chronic disease of the tonsils and adenoids are predisposing causes. Diph- 



296 DIPHTHERIA 

theria is more common in winter than in summer. It is more prevalent 
in cities, but it occurs very unaccountably at times in epidemic form in 
remote country districts. 

Pathology. — Diphtheria is primarily a local disease; its symptoms are 
largely due to the action of toxins. In prolonged cases more or less gen- 
eral infection with the diphtheria bacillus may occur. In these cases 
bacilli may be found in the blood, lymphatic tissues, liver, kidneys and 
other organs. The local lesions on the tonsils, soft palate, and uvula, or in 
the nose, larynx, and other respiratory passages, consist of an inflammation 
of the mucous membrane, which becomes hyperemic, swollen and infil- 
trated with cells. This is followed by the appearance of a grayish-white, 
sometimes brownish, pseudo-membrane, first occurring in patches and then 
spreading and forming a more or less continuous covering for the part 
affected. The severity of this process may vary from a mild pseudo-mem- 
branous sore throat to a necrosis, subsequent sloughing and destruction of 
the parts affected. An early myocarditis with acute cardiac dilatation may 
occur, or slower changes may take place in the heart muscle, producing a 
fatty degeneration of the muscle fiber, with a resulting replacement fibrosis 
and infiltration with small round cells. In the nerves we may have degen- 
erative processes, both parenchymatous and interstitial, which completely 
destroy their function. The sensory as well as the motor nerves may be 
affected. In the anterior horns of the spinal cord hemorrhages and de- 
generative changes may occur. If the disease is prolonged sepsis becomes 
a part of the pathological process, and may manifest itself by the ordinary 
lesions of a general septicemia or septicopyemia. 

Incubation Period. — This lasts from one to four days, and during this 
period there are no symptoms. 

Symptomatology. ■ — The ordinary eorm of diphtheria begins with a sore 
throat. The tonsils and pharynx are swollen, congested, and present one 
or more grayish-white patches which coalesce, forming a pseudo-membrane 
that gradually takes on a grayish-brown color. It may spread over the 
tonsils, uvula and pharynx, and may extend into the nose or through the 
larynx down the trachea into the bronchial tubes. Hand in hand with the 
extension of this membrane the local inflammatory conditions in the throat 
are increased, so that the patient may complain more and more of diffi- 
culty in swallowing. The odor from the breath may become fetid. The 
lymph nodes at the angle of the jaw, which are always enlarged, may be- 
come more and more swollen, involving the intervening connective tissue, 
producing a doughy-like swelling in the region of these glands. The pseudo- 
membrane may not only be seen in the locations described, but as the 
disease progresses it may be coughed up or discharged from the nose, and 
with the breaking loose of these membranes hemorrhages may occur. In 
mild cases the above local symptoms are very much modified, so much so 
that the patient may scarcely be conscious that he has anything more than 
a very mild tonsillitis; in the severe cases they may be greatly aggravated 
by the necrotic and gangrenous processes which occur. 



SYMPTOMATOLOGY 



297 



There may be headache, backache, general malaise, and an early rise of 
temperature reaching in the first twenty-four hours 102° to 104° P. The 
fever, as a rule, commences to fall within twenty-four or thirty-six hours; 
in uncomplicated cases it may reach normal within a few days. A sec- 
ondary rise is clue to some complication, usually of septic origin; when this 
occurs the temperature runs the irregular course of septicopyemia. The 
temperature may vary greatly ; in the most virulent cases it may be normal 
or even subnormal, so that from a diagnostic, as well as a prognostic, 
standpoint it may be very deceptive. 

The general prostration of the patient during the first twenty-four 



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hours of the disease is an important prognostic sign. The more profound 
the prostration the more severe the intoxication. In the most violent 
cases the patient is almost at once overwhelmed by the toxemia. Extreme 
prostration, high fever, rapid, feeble, irregular pulse with profound nerv- 
ous s} T mptoms, such as stupor, coma and convulsions, may be associated 
with hemorrhages from the mucous membranes, and with a purpuric rash 
over the body. These foudroyant cases, which may die within the first two 
days, are fortunately very rare. 

The blood presents no characteristic changes. There is a simple 
anemia and a marked leukocytosis, sometimes as high as 48,000. The 
polymorphonuclears are usually increased. 

Laryngeal diphtheria may be primary or secondary; fatal cases 



298 



DIPHTHEEIA 



are seen where the throat and pharynx present no evidence of a pseudo- 
membrane. A slight pseudo-membrane behind the pillars of the fauces 
may have been overlooked, but it is well to keep in mind the fact that 
laryngeal diphtheria in rare instances occurs with little or no preceding 
evidence of sore throat. The membrane, however, in a great majority of 
the cases extends from the throat into the larynx, and the symptoms of 
laryngeal diphtheria are therefore commonly preceded by some evidences of 
tonsillar or pharyngeal diphtheria. In extremely rare instances it is be- 
lieved that the membrane may occur primarily in the trachea or bronchial 
tubes and ascend to the larynx. The diagnosis of tracheal or below-the- 



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Fig. 49. — Laryngeal Diphtheria Treated by Intubation and with Antitoxin. 

larynx diphtheria is made by the coughing up of membranous casts from 
the trachea or bronchial tubes and by the failure of laryngeal operations 
to relieve the stenosis, and also perhaps by the evidence of unilateral block- 
ing of the bronchial tubes as made out by percussion and auscultation. 

The classical symptoms of laryngeal diphtheria are: a croupy cough 
of metallic character, increasing in severity and associated with a gradually 
increasing hoarseness, dyspnea, and loss of voice. The dyspnea is slightly 
worse at night, and slowly increases in severity day by day until the stridor 
and labored breathing may be heard in all parts of the room. On the 
third or fourth day the membrane in the larynx may cause complete ob- 
struction and end the life of the patient by suffocation. As the breathing 
becomes more and more difficult, the patient sits up in bed and fights for 



COMPLICATIONS 299 

air. All the accessory muscles of inspiration are brought into play as the 
child with tremendous effort attempts to force air into the lungs; the alae 
of the nose are dilated, the suprasternal notches are sunken in, the dia- 
phragmatic groove is contracted, and the whole attitude of the patient is 
characteristic of air hunger. The croupy cough comes on in paroxysms, 
is very persistent and is only temporarily, if at all, relieved by vomiting. 

Diphtheeia of the Eye. — True diphtheritic ophthalmia, before the 
days of antitoxin, was one of the most dreaded of all the complications of 
this disease, and it is still much feared because it so frequently results in 
loss of sight. The conjunctiva is violently inflamed and covered with a 
white or gray membrane. There is a profuse purulent discharge and the 
lids are so swollen that they can be separated with difficulty. The cornea 
quickly becomes involved and its destruction may cause loss of vision. 

Diphtheeia of the Vulva. — This is a rare complication, but it may 
occur in infants as a result of direct inoculation. The parts are much 
inflamed, swollen and covered with a pseudo-membrane. These cases com- 
monly run a benign course and terminate in recovery. 

Paralysis.- — The heart may suffer both early and late in the disease in 
the acute onslaught of very severe cases; asystole and diminished systole 
may result from splanchnic paralysis. During the second or third week 
vomiting, abdominal pain, cardiac gallop rhythm and irregular respiratory 
movements usually mean the involvement of the pneumogastric nerve. 
In both of these conditions there is imminent danger of cardiac paralysis. 
Between the third and the sixth week fatty degeneration of the heart muscle 
with cardiac dilatation may occur, and the heart's action may become ir- 
regular, intermittent and feeble, and a slight murmur may appear at the 
apex. These cases, however, commonly make a slow recovery, the cardiac 
weakness persisting for months after convalescence has been established. 
It should be remembered that a moderate degree of irregularity and dis- 
turbance of the cardiac rhythm may occur at any period of the disease 
without necessarily indicating serious cardiac involvement, but when the 
symptoms of splanchnic or vasomotor paralysis appear the life of the pa- 
tient is in imminent danger. 

The post-diphtheritic form of paralysis commonly occurs during ap- 
parent convalescence, from two to five weeks after the onset of the initial 
symptoms, and its appearance may confirm an uncertain diagnosis. This 
form commonly begins in the palate and is made evident by the nasal tone 
of the speech and by difficulty in deglutition; fluids taken into the mouth 
sometimes return through the nose. In these cases the patellar reflex 
should be studied as an indication of the probable extension of the paraly- 
sis; the absence of this reflex indicates approaching paralysis of the legs. 
This may be followed by paralysis of the muscles of the eyes, arms and 
trunk, gradually resulting in complete paralysis of almost all the voluntary 
muscles. The prognosis in this form of paralysis is favorable; a slow but 
complete recovery, extending over months, usually takes place. 

Complications. — General septicemia, or a septicopyemia, are common 



300 DIPHTHBKIA 

complications of diphtheria, and the course of the sepsis is similar to that 
described under Scarlet Fever. Severe cases of this character are usually 
associated with ulcerative and gangrenous sore throats, and with extensive 
cervical adenitis, involving the cellular tissue of the neck, which may or 
may not terminate in suppuration. This local symptom group is accom- 
panied by profound constitutional symptoms, such as marked prostration, 
a septic fever or subnormal temperature, a feeble, intermittent pulse and 
stupor, deepening into a semi-comatose condition. 

Otitis media, mastoiditis and purulent infections of the frontal and 
ethmoidal sinuses may occur. 

Bronchopneumonia is the most dreaded of all the complications. It 
occurs most frequently in septic and in laryngeal cases; it is especially to 
be feared following tracheotomy and intubation for laryngeal stenosis. It 
is found in 50 to 70 per cent, of fatal cases. The onset is marked by 
an increase in the fever, cough and dyspnea, and a careful physical 
examination reveals either a unilateral or a bilateral bronchopneu- 
monia. 

Nephritis, according to Baginsky, occurs in 42 per cent, of the severe 
cases. It is, however, a rather uncommon complication of the mild cases, 
and, as this type of the disease greatly predominates, it does not perhaps 
occur in more than 5 to 10 per cent, of all cases; a slight albuminuria, 
however, is observed in about 30 or 40 per cent. 

Simple enteritis occurs very frequently, but pseudo-membranous gas- 
troenteritis is very rare; when present, however, it usually causes a fatal 
termination. 

Course and Duration. — In simple tonsillar and pharyngeal diphtheria, 
the acute symptoms last from three to five days. In cases which are com- 
plicated by septic infection the disease may be indefinitely prolonged. 
The antitoxin treatment greatly shortens the course and modifies the se- 
verity of the disease. 

Prognosis.- — Age is a very important prognostic factor. During the 
first year the death rate is 50 per cent., the second year 30 per cent. ; after 
the seventh year 7 or 8 per cent. The severity of the infection is a deter- 
mining factor in the prognosis; some epidemics are very malignant, others 
are very mild; the character, therefore, of the prevailing epidemic may 
assist in determining the prognosis in an individual case. The parts af- 
fected very materially influence the prognosis; in laryngeal and tracheal 
diphtheria the death rate may reach 60 to 70 per cent.; in severe nasal 
diphtheria, with a complicating sepsis, the prognosis is also serious; in 
simple tonsillar diphtheria the prognosis is good. The previous condition 
of the patient may determine in part his powers of resistance, and may, 
therefore, influence the prognosis; in feeble, malnourished children the 
prognosis is not as good. The treatment is the important determining fac- 
tor in the prognosis. If antitoxin is given within the first twenty-four 
hours, less than 5 per cent, die; within the second twenty-four hours, less 
than 10 per cent. ; within the third twenty-four hours, about 20 per cent. ; 



DIAGNOSIS 301 

within the fourth twenty-four hours, about 40 per cent. In the laryngeal 
cases the death rate is reduced by antitoxin from 65 to 25 per cent. 

Diagnosis. — For the diagnosis of this disease the physician must depend 
first upon his clinical observations, and second upon the bacteriological 
findings. The clinical diagnosis is made by the appearance of a pseudo- 
membrane on the tonsils, uvula, pharyngeal wall, and sometimes in the 
nose and in the larynx, when it is not visible elsewhere. In most instances 
there is nothing absolutely pathognomonic in the appearance of this mem- 
brane, but the physician comes by experience to learn that grayish-white 
patches of pseudo-membrane, having a tendency to spread, and located as 
above noted, usually mean diphtheria, and that all such cases should have 
antitoxin at once before the result of the bacteriological examination denies 
or confirms the correctness of his diagnosis. The bacteriological findings 
are of the utmost importance, and if made early in the disease are more 
reliable than the clinical appearances. But it should be remembered that 
they are by no means infallible; for instance, in rare cases pseudo-diph- 
theria bacilli may cause confusion, or again the membrane may be so lo- 
cated in the air passages that it is not reached by the cotton-wrapped probe 
from which the culture is made, or late in the disease pyogenic cocci and 
other microorganisms may have so replaced the diphtheria bacilli that 
they are not found in the culture. Clinical and bacteriological findings, 
therefore, should go hand in hand. When they agree, as they do in most 
instances, there is no question as to the diagnosis ; when they disagree the 
patient should have the benefit of the doubt and be given antitoxin, and 
the subsequent history of the case will determine the wisdom of this action. 
From the standpoint of preventive medicine, the laboratory diagnosis is 
all-important. It is relied upon to determine whether a quarantine shall 
be established and when it is to be discontinued. Patients should not be 
discharged until a negative throat culture has been obtained. Paralysis 
of the soft palate and other post-diphtheritic paralyses may often make 
a late diagnosis of diphtheria in cases that were supposed to have suffered 
from follicular tonsillitis. The paralysis which follows diphtheria is a 
neuritis and is to be differentiated from infantile paralysis and cerebral 
palsy; this differentiation, however, is taken up under the latter disease. 
It is only important here to note that a paralysis which occurs with or 
follows a membranous sore throat and which begins in the palate is, in 
almost every instance, due to diphtheritic neuritis. Traumatic pseudo- 
membranes following operations on the tonsils, or injury to the throat or 
mouth from caustic alkalies, may be differentiated from true diphtheria 
by bacteriological findings and by the previous history and symptomatology 

Diphtheritic laryngitis may be differentiated from spasmodic catarrhal 
croup by the following points : In catarrhal laryngitis the attack of croup 
comes on suddenly, usually in the early part of the night ; the child wakes 
up with a hoarse, barking cough, struggles for breath and has a laryngeal 
stridor that can be heard in all parts of the room. The attack reaches 
its height the first night; the next day the child is comparatively com- 



302 DIPHTHEEIA 

f ortable, with perhaps a little hoarseness and croupy cough ; the second and 
third nights the attack may be repeated, but grows less severe. In laryn- 
geal diphtheria, however, the laryngeal stridor comes on more slowly, grad- 
ually increasing in severity for three or four days, until the child's life 
is imperilled by strangulation; the stridor also continues throughout the 
day ; it may be worse at night. The presence of a membrane in the throat, 
and a bacteriological examination, may assist in the diagnosis. An emetic, 
which gives such prompt relief in simple laryngitis, has little influence on 
the laryngeal stridor of diphtheritic croup. If necessary the administra- 
tion of chloroform may be resorted to, to assist in the diagnosis ; chloroform 
relieves the stenosis of simple laryngitis, but has little influence in laryn- 
geal diphtheria. 

Prophylaxis. — As a matter of general prophylaxis all children having 
diseased tonsils, adenoids or nasal mucous membranes should have these 
parts properly treated, and, if possible, put in normal condition so that 
they may be less predisposed to contagion. Children who have been ex- 
posed to diphtheria should be given an immunizing dose of from 500 to 
1,000 units of antitoxin and should also have their throats and noses care- 
fully douched with physiological salt solution, or with some alkaline anti- 
septic. In exposed institutional children the immunizing dose of antitoxin 
should be repeated in three weeks. 

Although the radius of infection in diphtheria is more contracted than 
it is in most of the contagious diseases, the patient should be isolated and 
a rigid quarantine instituted, which should be continued until convalescence 
is established and until a bacteriological examination of the throat has 
demonstrated that it is free from diphtheria bacilli. The preparation of 
the sick room and other details of quarantine are described in the chapter 
on Scarlet Fever. In the average case of diphtheria the quarantine 
lasts two weeks. 

Treatment. — In diphtheria antitoxin, discovered by Behring in 1890, 
we have a specific remedy that can be relied upon to exert a curative 
influence in every case when it is given at the proper time and in the proper 
dosage. It is prepared from the blood serum of the horse, immunized by 
gradually increasing doses of the diphtheria toxin. The horse serum thus 
obtained contains an antitoxin which combines with and neutralizes the 
toxin of diphtheria, and quickly brings to its termination the localized 
inflammation caused by the diphtheria bacillus. This specific antitoxin 
came into more or less general use in 1894, following an exhaustive in- 
vestigation by M. Eoux of the work which had been done upon this subject 
up to that time. This paper was so convincing that antitoxin was at once 
accepted by the medical world as a specific remedy for diphtheria. From that 
day to the present time it has been in general use and as a result the. mor- 
tality from diphtheria throughout the world has been enormously diminished. 
The testimony wherever this remedy has been systematically and intelligently 
used is so absolutely convincing as to its specificity that it is difficult to un- 
derstand at the present day how there can be any opposition to its use. 



TREATMENT 



303 



The following chart from McCollom graphically illustrates the value 
of antitoxin in decreasing the death rate of diphtheria : 



DIPHTHERIA 












1 


NTU 


BATI 


ON_ 














PERCENT 

OF 

MORTALITY 


NO ANTITOXIN 


ANTITOXIN 


1888 


18S9 


1890 


1891 


1892 


1893 


1891 


1895 


1896 


1897 


189S 


1899 


1900 


1901 


1902 


190S 


1904 


85.00 

80.00 

75.00 

70.00 

65.00 

60.00 

55.00 

50.00 

45.00 

40.00 

35.00 

30.00 

25.00 

20.00 

15.00 

10.00 
5.00 










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Fig. 50. — Per Cent, of Mortality of Diphtheria at the Boston City Hospital, Proper, 
and at the South Department from 1888 to 1904, Inclusive. Per Cent, of Mor- 
tality of Intubations for the Same Time. 1888 to 1894 no Antitoxin. 1895 to 
1904 Antitoxin. (McCollom.) 

Antitoxin should be given by subcutaneous injection in the loose tissue 
of the back below the angle of the scapula, of in the buttocks. The skin 
should be carefully scrubbed and disinfected, and the injection made with 
a sterilized syringe. At the present time the various manufacturers furnish 
antitoxin in sterile syringes ready for use. In uncomplicated tonsillar or 
pharyngeal diphtheria the initial dose should be 4,000 units, except in in- 
fants under one year of age, to whom 2,000 or 3,000 units should be given. 
If the symptom group be not greatly improved, a second' dose should be 
given eight hours later. In neglected cases, coming into the hands of the 
physician on the third or fourth day of the disease, the treatment should be 
begun with 10,000 units, and this dose repeated in eight hours, if no im- 
provement is noted. In laryngeal diphtheria the initial dose should be 
10,000 units, and if the laryngeal stenosis be not relieved, from 40,000 to 
50,000 units- should be administered within the next three days. After a 
large experience with this class of cases, in the wards of a city hospital, I 
am convinced that the mortality in laryngeal diphtheria would be less and 
the number of operative cases fewer if they were treated with large doses. 
In diphtheria of the eye large doses of antitoxin are necessarv to save the 
21 



304 DIPHTHERIA 

eye; 10,000 units should be given every six hours until the purulent con- 
junctivitis is controlled. To a child three years of age I recently gave 
70,000 units over a period of four days, with the result that the eye was 
saved and no untoward symptoms followed the antitoxin. The local treat- 
ment should be directed by an oculist; it consists in ice-cold applications, 
the frequent irrigation of the eye with a 3 per cent, boracic acid solu- 
tion, and the dilatation of the pupil with atropin. If only one eye is 
affected, the other should be covered with a watch glass and carefully sealed 
with adhesive plaster and collodion to prevent its infection. 

In advocating large and frequent doses of antitoxin in the cases of 
diphtheria which threaten life or endanger the eye, I do not wish to con- 
vey the impression that these large doses are necessary in the simpler forms 
of diphtheria seen in private practice. As previously noted, most of these 
cases recover promptly under from 4,000 to 8,000 units of antitoxin, and 
the giving of enormous doses unnecessarily, while it may do no harm, 
entails an expense which prejudices the public against the use of this most 
valuable of all remedies. The only unpleasant results that I have ever 
seen from antitoxin are the skin rashes which so commonly follow its use, 
and the size of the dose has little to do with the appearance of these rashes. 
Certain anaphylactic phenomena may occur as annoying sequels of the 
antitoxin treatment; the most common of these is urticaria; more rarely 
a rash, morbilliform or scarlatinaform in character, may appear, which in 
connection with the sore throat may suggest scarlet fever; arthralgia and 
enterocolitis are occasionally seen. It is believed that, in children of 
asthmatic constitution, dangerous and even fatal anaphylactic phenomena 
may occur. I have never seen such a case. 

Local Treatment. — Before the days of antitoxin the life of the child 
often depended upon the thoroughness with which the throat and nose 
were cleansed with antiseptic sprays, gargles and douches. The throat 
and pharynx should be swabbed alternately with a 1:1000 bichlorid of mer- 
cury and 20 per cent, argyrol solutions in the bad cases of nasal and 
pharyngeal diphtheria in which the septic cocci are playing an important 
role in producing symptoms. Where the lymphatic glands of the neck are 
acutely inflamed an ice-bag is the best application. If this enlargement 
continues for a number of days poultices may be substituted for the ice 
and, if suppuration occurs, the abscess is to be opened. 

In laryngeal diphtheria steam inhalations are of some value, and com- 
bined with this, calomel may be sublimed. The croup kettle and calomel 
sublimations, however, which were such important parts of the treatment 
before the days of antitoxin, are now but rarely used. They have a certain 
degree of efficacy which should justify their remaining a part of the treat- 
ment of laryngeal diphtheria; however, when the pseudo-membrane pro- 
duces such stenosis of the larynx that the child is becoming exhausted in 
its efforts to force air into the lungs, this stenosis must be relieved either 
by tracheotomy or intubation, but following either of these operations the 
antitoxin treatment is to be continued. Of these two operations intubation 



TKEATMENT 305 

is universally recognized to be the best. It has many advantages over 
tracheotomy, it is bloodless and therefore not objected to by the parents, it 
is quickly accomplished and serves the purpose of relieving the stenosis, 
and is less likely to be followed by bronchopneumonia than is tracheotomy. 
On the other hand, intubation cases require more careful watching; for 
this reason, in remote country districts, where the patient cannot be 
under constant supervision, tracheotomy is to be preferred. It is also to 
be used where intubation fails to relieve the stenosis, or when the tube is 
frequently coughed up. 

Intubation. — Dr. Joseph O'Dwyer, of New York, in 1883 perfected 
intubation, and the intubation set which he devised remains to-day, with 
unimportant modifications, in general use. The O'Dwyer intubation set 
consists of seven tubes made of vulcanized rubber on a metal frame; a 
gauge for determining the size of the tube suitable to the age of the pa- 
tient; obturators and a handle for manipulating the tubes in their intro- 
duction; an extractor for removing the tubes from the larynx, and a gag 
for holding the mouth open during the operation. The patient is wrapped 
in a blanket with his arms at his sides and held firmly, sitting upright in 
the lap of the nurse, or placed on a table in a horizontal position with the 
head thrown backward; the recumbent position is to be preferred. The 
jaws are widely separated by the introduction of the mouth gag, which 
is held firmly in position by an assistant. The introducer, with tube at- 
tached, is held in the right hand, and the forefinger of the left hand is in- 
troduced into the mouth and directed downward over the tongue until the 
epiglottis is felt. This is hooked forward and the finger inserted into the 
chink of the glottis. With the tip of the finger in this position the tube 
is inserted into the mouth, following the line of the finger, being careful 
to keep it in the median line until it reaches the chink of the glottis. As 
it enters the larynx the introducer is removed and the tube pushed into 
position by the left index finger. If the tube is in proper position the 
symptoms of stenosis are promptly relieved. If the operation has been 
unsuccessful, the tube may be withdrawn by the thread to which it was 
attached before its introduction, and the process repeated until successful 
intubation is accomplished. An anesthetic is unnecessary in this operation. 
After a variable period of from one to six days, when the disease has come 
under the control of antitoxin^ the tube should be removed. This operation 
is more difficult than inserting the tube. The index finger of the left hand 
is introduced as before until it reaches the head of the intubation tube. 
With this finger as a guide the extractor is inserted and the tube with- 
drawn. If the stenosis returns the tube is to be again inserted. 

In skilful hands, intubation is a comparatively simple operation 
which can be performed with little danger to the patient. Where the 
pseudo-membrane is extensive the tube may push the membrane before it 
into the trachea, causing obstruction, which is commonly relieved by a vio- 
lent fit of coughing and the expulsion of the detached membrane. If 
suffocation threatens, tracheotomy may be necessary to save the life of the 



306 



DIPHTHBEIA 



child. The high operation above the isthmus of the thyroid is to be pre- 
ferred, since it is less difficult and is attended with less bleeding; occa- 
sionally the low operation may be necessary. Following intubation, care 
must be exercised in feeding to prevent the passage of food material 
through the tube into the bronchi; this accident produces violent fits of 
coughing. It was formerly believed that food entering in this way was 
a common cause of pneumonia, but the carefully devised experiments of 
Northrup have shown that there is little or no danger from "food pneu- 
monia." In a few cases it may be necessary in giving fluids to place the 




Fig. 51. — Intubation Position. 

child upon its back with its head thrown backward over the side of the 
bed, so that the pharynx is lower than the larynx. In very rare instances 
it may be necessary to introduce food through a stomach tube. Bromid 
of potash combined with belladonna in some palatable vehicle may be of 
value in relieving the cough and irritation of laryngeal cases in which a 
tube has been inserted. 

General Treatment. — The child is confined to bed even in the mild- 
est cases because of the danger of cardiac paralysis. Absolute quiet should 
be insisted upon until convalescence is fully established. The patient 
throughout his illness should have fresh air night and day, and be placed 
under the best hygienic conditions possible. Throughout the treatment the 



TKEATMENT 307 

diet should be largely milk. Ice-cream is especially grateful to many of 
these cases, and it may be given freely. Cereals may also be allowed. 
From the beginning, albuminous foods, however, such as meat and eggs, 
should be dispensed with until convalescence is established. In severe and 
neglected cases whiskey and brandy should be given in good-sized doses, 
well diluted — a teaspoonful every two or three hours for a child three or 
four years of age. In these cases also stimulation may be necessary.' 
Strychnin, cafTein sodium benzoate, strophanthus, digitalis and normal salt 
solution may be given as indicated to sustain the pulse, overcome exhaus- 
tion and prevent collapse. In more desperate cases camphor and ether 
may be used hypodermically. 

Treatment of Complications. — In the treatment of splanchnic par- 
alysis previously referred to, Forchheimer says: "My remedies for vaso- 
constriction are adrenalin and cafTein, administered hypodermically. Ad- 
renalin especially possesses the property of producing contraction in the 
blood vessels supplied by the splanchnic nerve; as its effects are transitory, 
it must be administered frequently — every two to three hours in the 1 :1,000 
solution, of which from 1 to 1.5 c. c. are given at a dose. Caffein sodio- 
salicylate may be given, combined with adrenalin or alone; when the pa- 
tient begins to improve, caffein alone is given (v. Chronic Myocardial In- 
sufficiency), the adrenalin being gradually discontinued, because I have 
found that the action of caffein is more lasting than that of adrenalin. 
Further, I apply two or three ice-bags to the abdomen, to act upon the 
abdominal reflex, because this increases blood pressure and reduces fre- 
quency of systole." 

Septicemia becomes a part of the pathological process in untreated cases 
by the third or fourth day. These cases should therefore be treated not 
only for diphtheria, but also for septicemia. If they do not yield readily 
to large doses of diphtheria antitoxin, then anti-streptococcic serum and 
inunctions of unguentum Crede should be given (see Scarlet Fever). The 
latter is especially indicated in severe inflammation of the lymphatic glands 
of the neck. 

Bronchopneumonia is to be treated as outlined under the treatment 
of this disease, except that the onset of a pneumonia complicating diph- 
theria is an urgent indication for large and repeated doses of antitoxin. 
The pneumonia in these cases is caused by the extension of the pseudo- 
membrane into the smaller bronchi, and any treatment other than antitoxin 
is of little avail. 

Post-diphtheritic Paralysis. — This is to be treated by large and re- 
peated doses of diphtheria antitoxin. Comby has clearly demonstrated the 
value of this remedy in the cure of diphtheritic neuritis. From 3.000 to 
4,000 units of antitoxin should be given daily over a period of eight or 
ten days. While antitoxin greatly shortens the duration of the post-diph- 
theritic paralysis, it should be remembered that in nearly every instance, 
even in the absence of this treatment, time restores the function of the 
nerve and cures the paralysis. In addition to the specific treatment with 



308 INFLUENZA 

antitoxin post-diphtheritic paralysis is to be treated as outlined in the chap- 
ter on Neuritis. Good food, fresh air and proper hygiene are important, 
and following the acute symptoms general massage and electricity are of 
advantage. 

CHAPTER XXXVIII 
INFLUENZA 

Influenza is an acute infectious and highly contagious disease caused 
by the influenza bacillus. It is characterized by fever and acute catarrhal 
processes, especially of the respiratory passages. 

Etiology. — The influenza bacillus, discovered by Pfeiffer in 1892, is the 
exciting cause. The bacillus septus, the pneumococcus, the micrococcus 
catarrhalis, the pyogenic cocci and other microorganisms may produce 
symptom groups characterized by catarrh of the respiratory passages which 
cannot easily be differentiated from influenza. These cases are spoken of 
as common colds or epidemic coryzas and are to be treated in the same 
manner as true influenza. 

The Pfeiffer bacillus is found in great numbers and almost in pure 
culture in the mucous discharges from the nose, throat and bronchi in the 
early stages of influenza; later it is associated with streptococci, staphy- 
lococci and pneumococci, which are found not only free but within the pus 
cells. It is also commonly found in catarrhal discharges from the respira- 
tory passages where there is an entire absence of ordinary acute influenza 
symptoms; such cases, it is believed, represent a localized chronic phase 
of this disease, and are associated with inflammation of adenoids, bron- 
chitis or apex catarrh of the lungs. Influenza bacilli are also associated 
with pyogenic organisms in chronic pus forming processes such as otitis 
media and infections of the sinuses of the face. The Pfeiffer bacillus 
rarely produces infection in lower animals. Inoculation experiments have 
for the most part resulted in failure. 

The specific cause of this disease is commonly spread by coughing, 
sneezing and expectorating. The danger lies not only in the moist bacilli 
thus discharged, but in the dried bacilli which may contaminate public con- 
veyances, homes, schools and other places where people are gathered to- 
gether indoors. Influenza bacilli are so readily disseminated both in the 
dry and in the moist state that the disease is highly contagious and spreads 
rapidly through households, schools and communities in epidemic form. 
A number of pandemics of this disease have occurred; the last one in 
1889, when 30 or 40 per cent, of the entire population of our large cities 
suffered more or less from it. Since that time the disease has been present 
to a greater or less extent in all of our large cities, so that occasional 
cases may occur throughout the year. The influence of climate in favor- 
ing its spread is shown by the fact that it becomes epidemic during the 
winter months, beginning usually before the first of January, reaching a 



SYMPTOMATOLOGY 309 

maximum in February, and gradually subsiding in the early spring. One 
of the noticeable features of these epidemics is house infections, the disease 
persisting throughout the winter and early spring in certain houses. The 
children living therein suffer during this time from frequent recurring at- 
tacks of mild influenza, which are probably due to reinfection. In other 
instances these repeated attacks may be due to relapsing or chronic in- 
fluenza, the Pfeiffer bacillus never entirely disappearing from the adenoids, 
tonsils, sinuses and other of their favorite hiding places. 

Nursing infants under six months of age are practically immune, and 
the disease is comparatively infrequent during the second six months of 
life. It may, in rare instances, occur even in the new-born. After the 
first year susceptibility to this disease rapidly increases, so that children 
three or four years of age are almost, if not quite, as susceptible as adults. 
It is common even in old age. At the two extremes of life the disease, by 
reason of its complications, is more dangerous. 

Pathology. — The pathological changes which properly belong to in- 
fluenza are those of a catarrhal inflammation of the mucous membrane of 
the respiratory passages. The accessory sinuses are not infrequently in- 
volved and the tonsils, adenoids and neighboring lymphatic glands are 
enlarged by congestion or inflammation. The mucous membrane of the 
intestine may be acutely inflamed, and almost every organ and tissue of 
the body may be either directly or indirectly injured by the Pfeiffer 
bacillus and the pyogenic organisms which are so commonly associated 
with it in its destructive processes. 

Incubation. — The average period of incubation is from two to three 
days, but it is commonly believed that this period may vary from twelve 
hours to a week. 

Symptomatology. — The symptom group presented by influenza is very 
variable, and different epidemics may be characterized by the predominance 
of a certain set of clinical symptoms, which in another epidemic may be 
largely in abeyance. The most characteristic symptom group, however, is 
that produced by catarrhal inflammation of the respiratory passages. 

Onset. — The temperature rises rapidly, in some instances reaching 
105°F. within the first twenty-four hours; the younger the child the 
higher and the more rapid the rise of the temperature; there may be a 
sensation of chilliness or even a decided rigor; in infants convulsions may 
occur. The discomfort of this period is very acute, the head. back, and 
every part of the body may ache, and there is usually complete loss of 
appetite with more or less gastric disturbance. The prostration is marked, 
quite out of proportion to the other symptoms, and the child presents the 
appearance of being very ill. The younger the child the more pronounced 
are these general symptoms. The fever may begin to fall within thirty-six 
hours, but commonly does not reach normal until the third or fourth day. 
It may, however, be prolonged by various complications. In subacute or 
chronic forms of the disease the temperature after reaching normal may 
slowly rise again, and a slight and variable fever may last for weeks. 



310 INFLUENZA 

Coryza, which is one of the most characteristic symptoms, may occur 
early in the disease, but is usually delayed until the second day. Tonsil- 
litis and pharyngitis as a rule precede the coryza. The pharynx is markedly 
congested, the tonsils enlarged, and not infrequently a complicating infec- 
tion produces a white exudate. These symptoms are usually followed 
by bronchitis or laryngitis, which give rise to an irritating cough which 
may be hoarse and paroxysmal in character, in some instances resembling 
the whooping-cough paroxysm. 

Nervous Symptoms. — In young children the disease may commence 
with vomiting, stupor and symptoms of meningeal irritation, closely re- 
sembling a beginning meningitis. This profound toxemia, involving the 
nerve centers, while not so common, may occur in older children. Head- 
ache and extreme nervous irritability are common symptoms, and in older 
children neuralgic pain is a very common occurrence. Almost any nerve 
in the body may be affected, but the supraorbital is most commonly so. 
Severe intermittent supra- or infraorbital neuralgia, persisting after the 
acute symptoms have subsided, is strongly suggestive of sinus infection. 

Acute gastroenteritis is very frequently caused by influenza; this 
manifestation is usually spoken of as intestinal grippe. It commonly 
follows, but it may occur quite independently of the catarrhal symptoms 
on the part of the respiratory tract. It is much more frequent in young 
than in older children, because at this age the bronchial mucus carrying 
infection is swallowed and the intestinal mucous membrane is perhaps less 
resistant. With the onset of this condition there may be nausea, vomiting, 
increase of fever and a sharp diarrhea. The discharges are putrid and 
contain large quantities of mucus which may be tinged with blood. The 
symptoms of an ordinary acute enterocolitis may follow, last for weeks, 
and place the patient's life in jeopardy; especially is this true in infancy. 
These cases occurring in older children may resemble typhoid fever. 

An erythematous rash is frequently present during the acute stages of 
influenza. It may be very slight or it may be very marked, covering almost 
the entire body, presenting an exanthem very like that of scarlet fever; it 
commonly disappears within twenty-four or thirty-six hours. Other skin 
eruptions may appear, such as urticaria and a roseola somewhat similar 
to the rash of measles; these eruptions are all evanescent, and therefore 
do not commonly embarrass the diagnosis for more than twelve or twenty- 
four hours. 

Blood. — Lord and other observers have found a slight leukocytosis in 
this disease, which becomes more marked when the influenza is compli- 
cated by septic processes, or when a more or less latent glandular tuber- 
culosis has been rendered active by an attack of influenza. 

The clinical picture of influenza above given may be greatly varied by 
the absence of certain symptom groups. In some instances the catarrhal 
symptoms on the part of the nose, throat and upper air passages may be 
very marked and very persistent, with slight fever and no nervous or other 
constitutional symptoms. In other cases the catarrhal symptoms of the 



COMPLICATIONS 311 

respiratory tract may be entirely absent, the fever and nervous symptoms 
predominating and producing a clinical picture quite unlike that of ordi- 
nary influenza. In other instances, especially in young children, gastro- 
enteric infection followed by an enterocolitis may occur without preliminary 
catarrhal symptoms on the part of the respiratory tract. That is to say, 
this disease may present itself in three well-marked symptom groups : the 
first and most characteristic is produced by catarrh of the respiratory 
passages; the second by the systemic intoxication; the third by gastro- 
enteric infection. The clinical picture may present a combination of these 
three groups, any one of which may predominate, or may be absent. 

In infants and very young children the clinical syndrome of acute 
influenza may present certain peculiarities. The general infection is more 
severe and more sudden in its onset. Vomiting, convulsions, lack of appe- 
tite, apathy, stupor, opisthotonos and other symptoms closely simulating a 
beginning meningitis may occur. The fever is higher and rises more sud- 
denly. Gastrointestinal infection with resulting catarrh is much more 
frequent. The erythematous exanthem is more frequently seen. The 
catarrhal symptoms appear later. The coryza is not generally so marked. 
The bronchitis which occurs late is much more serious than in older chil- 
dren, and pneumonia is more common. 

Chronic Influenza. — The course of an uncomplicated influenza 
varies from three days to two weeks, and within this time the patient 
should and commonly does entirely recover. A few cases, however, by rea- 
son of the fact that they have influenza bacilli concealed in their tonsils, 
adenoids or some of the accessory sinuses of the nasopharynx, suffer from 
repeated mild relapses of attacks, the disease in this way becoming chronic. 
These cases frequently have enlarged and diseased adenoids or tonsils ; they 
suffer from a low fever which may, for a few days at a time, reach normal 
or even fall below normal, to be followed again by a slight rise of tempera- 
ture, rarely above 102 °F. These acute exacerbations of fever may be asso- 
ciated with headache and general discomfort and in older children periodic 
neuralgias may occur. The patient fails to regain his appetite, is weak, 
anemic, and loses in weight and strength. The catarrhal symptoms on 
the part of the respiratory mucous membrane are more or less prominent ; 
a spasmodic cough, resembling whooping-cough, may continue for weeks, 
but differs from the whooping-cough paroxysm in that it is less violent, is 
not aggravated at night and is not usually accompanied by the whoop or 
followed by vomiting. The rhinitis, while not very acute, is commonly 
present to a greater or less degree. 

Immunity. — One attack does not confer immunity for any great period 
of time, but it does offer a degree of temporary protection. It is a mat- 
ter of clinical record that influenza has appeared in a milder form since 
the great epidemics of 1889 and 1891 ; this is perhaps due to the fact that 
a great percentage of the population have, from previous attacks, acquired 
a certain degree of immunity. 

Complications. — Otitis media is such a common complication that the 



312 INFLUENZA 

ear drums should be examined in every case. In this condition the influ- 
enza bacilli are associated with septic organisms and may produce a 
mastoiditis. The frontal and ethmoidal sinuses may be affected, especially 
in older children. Albuminuria occurs very commonly in children suf- 
fering from influenza. Acute hemorrhagic nephritis may develop very 
suddenly during the height of the disease; these cases not infrequently 
have a fatal termination. Post-grippe nephritis is less violent and runs 
a much more benign course than the hemorrhagic form. I believe 
that a large percentage of the cases of so-called idiopathic nephritis as 
well as those supposed to be produced by exposure to "cold," are cases 
of influenzal nephritis, having their origin in a recent attack of this disease ; 
I also believe that influenza is one of the most common causes of chronic 
nephritis, and I feel quite sure that our text books and medical literature 
have not given to this subject the prominence it deserves. Tuberculosis 
is one of the most serious and common complications; an attack of in- 
fluenza may aggravate an existing pulmonary or lymph-node tuberculosis. 
A prolonged bronchopneumonia with migrating areas of consolidation 
may be produced by the influenza bacillus. Conjunctivitis and other in- 
flammatory conditions of the eye may occur. The heart may be over- 
whelmed by the toxemia, much as it is in diphtheria, and a myocardial 
weakness may persist for months after the acute symptoms of the disease 
have disappeared. In rare instances a splanchnic paralysis may occur. 

Diagnosis. — It is practically impossible to differentiate mild cases of 
influenza from other catarrhal conditions of the respiratory passages. The 
pneumococcus, the micrococcus catarrhalis, and other microorganisms pro- 
duce similar conditions of the nose, throat and bronchi, which can only be 
differentiated by an early bacteriological examination. In private prac- 
tice this is rarely resorted to, as the differential diagnosis of these condi- 
tions from a clinical standpoint is not very important, since we have no 
specific treatment, and all are treated alike in a purely symptomatic way. 
From tuberculosis, influenza can be differentiated by the absence of the 
tuberculin skin reaction and by the failure to find tubercle bacilli in the 
sputum; from meningitis, by an examination of the cerebrospinal fluid and 
by the subsequent history of the case; from typhoid fever, by the absence 
of rose spots, the Widal reaction, and other symptoms of typhoid. 

Prognosis. — The prognosis of uncomplicated influenza is almost always 
good. In rare instances young children are overwhelmed by the toxemia 
and death may result from cardiac paralysis, cerebral congestion, or intes- 
tinal toxemia. Apart from this the danger lies in its many complications, 
such as bronchopneumonia, acute Bright's disease, and mastoiditis, which 
may result fatally. 

Prophylaxis. — Patients suffering from acute influenza should be isolated 
from other members of the household. This is especially important dur- 
ing the early acute catarrhal stage, as this is the period of greatest in- 
fection. The very young, the old, and individuals suffering from tubercu- 
losis and other chronic diseases should be protected from this contagion, 



TREATMENT 313 

since among this class of patients the disease is unusually severe and 
its complications especially dangerous. House disinfection is a most 
important prophylactic measure; in homes that are infected with this 
contagion the disease may continue to recur among the children of the 
family from time to time throughout the winter and spring months; for- 
maldehyde disinfection may prevent these reinfections. Catarrhal dis- 
charges from the respiratory passages should be destroyed. Individual 
prophylaxis is also of importance. Much can be done by having the well 
children of the family spray or douche their noses and throats once a day 
with a mild alkaline antiseptic. They should also spend as much time as 
possible out of doors, and their physical condition should be looked to, if 
necessary, by the administration of cod-liver oil, iron and other tonics. 
This is especially important in families having a tuberculous family history. 
Treatment. — The patient should be confined to bed during the acute 
stage of the disease. Rest in bed is a most important curative measure. 
The diet should be simple, suited to the age of the child, and especially 
selected with reference to throwing little work upon the excretory organs. 
Milk, cereals, bread and in older children fruit juices should be recom- 
mended. Albuminous foods, such as meats and eggs, are to be avoided 
during the acute stage, and but sparingly allowed during early convales- 
cence. The patient should be induced to drink as much water as possible, 
as this helps to modify the febrile symptoms and to promote the excretion 
of poisons. A lukewarm tub bath once or twice a day is not only grateful, 
but is a valuable therapeutic measure, as it quiets the nervous symptoms 
and promotes elimination. The medical treatment should begin with a 
dose of calomel. This is to be followed by a mild saline cathartic such as 
phosphate of soda or Rochelle salts, and throughout the course of the 
disease mild cathartic medication may be necessary. Quinin is the most 
valuable remedy in the treatment of influenza. In children under five 
years of age from 1 to 4 grains of euquinin may be given every three or 
four hours. Quinin in this form can usually be administered without pro- 
ducing gastric disturbance; if discomfort follows its use, it should be dis- 
continued. In children over five years of age the bisulphate or some of 
the other preparations of quinin may be given in pill or capsule, or com- 
bined with chocolate or licorice as recommended in the chapter on Malaria. 
Benzoate of soda is a remedy of value in the routine treatment of influ- 
enza. It should be given every four hours in doses of from 1 to 5 grains, 
according to the age of the child. It may be advantageously combined with 
tincture of belladonna. Phenacetin is a drug almost universally used and 
almost universally abused in the treatment of influenza. It is, however, of 
value when judiciously given. Of all the coal-tar products it is perhaps 
the least objectionable. It may be given to modify the headache, fever, 
and distressing symptoms at the very onset of the disease, but should not 
be continued longer than is absolutely necessary. It adds very materially 
to the comfort of the patient during the first two or three days, but exer- 
cises no curative influence on the disease, and if prolonged it may increase 



314 IiSTFLUENZA 

prostration and cardiac weakness. For a child one year of age, 1 grain 
may be given every three or four hours, increasing the dose one-half grain 
for every year of life until the maximum dose of 3 grains is reached. As- 
pirin is a remedy of perhaps equal value with phenacetin and may be 
used in the same dosage. Salol is especially to be recommended for infants 
and young children and should be substituted for the phenacetin and as- 
pirin in those cases where the acute discomfort is not great enough to 
demand the use of these drugs ; it may be given in twice the dosage recom- 
mended for phenacetin. 

Splanchnic paralysis and cardiac weakness occurring in this disease are 
to be treated as recommended in the chapter on Diphtheria. 

The coryza and pharyngitis may be treated by local applications of mild 
antiseptics. In infants and young children 10 minims of the oil of eucalyp- 
tus may be combined with 1 ounce of liquid albolin, and this may be 
dropped into the nose with a medicine dropper at three or four-hour in- 
tervals. For older children 2 grains of menthol may be added to this 
prescription and this applied to the nose and throat with an atomizer. 
Weak alkaline antiseptic sprays may also be used to cleanse and disinfect 
the mucous membranes of the throat and nasopharynx; these may precede 
by one hour the albolin spray above mentioned. When the acute symp- 
toms have subsided the course of the coryza and pharyngitis can be greatly 
shortened by the systematic use twice a day of these local applications. 

The cough which accompanies the bronchitis and laryngitis of this 
disease requires treatment. For this purpose the bromid of soda and tinc- 
ture of belladonna, put up with glycerin and some palatable elixir, may 
be used. For a child three years of age 4 grains of bromid of potash and 
1 minim of tincture of belladonna may be given at four-hour intervals. 
Where the cough is very irritable and harassing heroin or codein may 
be combined with this prescription. Heroin hydrochlorate (1/150 grain) 
and codein sulphate (1/40 grain) may be given to a child five years of age. 
It is advisable, however, to avoid opium and all its derivatives, when pos- 
sible, and they should rarely be given to children under two years of age. 
Acute gastroenteric infection and resulting enteritis are to be treated as 
directed in the chapters on these conditions. 

In influenza the physician should bear in mind that we have no specific 
treatment, and that the condition is a self-limited one, which has a tendency 
to run a benign course even if no medication is used. The medical treat- 
ment, therefore, should be as simple as possible, and only such drugs used 
as are especially demanded by the symptoms present. Chronic influenza 
yields most readily to climatic treatment. These cases should be sent to 
a warm and equable climate where the patient may live out of doors. 

After-treatment. — It is most important that the physician should be 
thoroughly awake to the fact that an active bronchial lymph-node tuber- 
culosis is not uncommonly lighted up by an attack of influenza; in the 
after-treatment of these cases a warm equable climate, cod-liver oil and iron 
are most important. Many cases of influenza, in which there is no trace 



ETIOLOGY 315 

of tuberculosis, are left in an anemic and weak condition; they are also 
benefited by the cod-liver oil and iron treatment. In children who have 
suffered from prolonged attacks of influenza, characterized especially b} 7 " 
catarrhal conditions of the nasopharynx, a careful examination of the ton- 
sils and adenoids should be made, and if these tissues be diseased or en- 
larged they should be removed; this is a most important curative measure. 
In many instances, in children suffering from recurring attacks of catarrhal 
influenza, I have, in the interval between these acute attacks, when the 
catarrhal symptoms were more or less in abeyance, had the tonsils and 
adenoids removed, with the result that a troublesome cough which had per- 
sisted for months would disappear and other catarrhal symptoms gradually 
subside. 



CHAPTER XXXIX 

SCARLET-FEVER 

(Scarlatina) 

Scarlatina is an acute infectious and very contagious disease, character- 
ized by fever, sore throat and a punctate scarlet rash which may cover the 
entire body and which is followed by widespread desquamation of the 
superficial epithelial layers of the skin. 

Etiology. — Predisposing Causes. — Scarlet fever is a disease of child- 
hood; it may, however, occur at any period of life. The young adult grad- 
ually acquires more or less immunity, so that in middle life the disease is 
comparatively rare, and much less severe, often manifesting itself as a mild 
attack of scarlatinal angina. It is also very rare during the first year 
of life. The comparative immunity which is enjoyed by the young infant 
is probably due to immune bodies derived from placental blood and is kept 
up to a degree by the breast milk. McCollom says that young infants are 
more susceptible than children of any other age; Heubner, on the other 
hand, never saw a case under six months of age. The explanation of these 
widely differing opinions lies in the probability that it is the nursing in- 
fant only that enjoys this comparative immunity, and that bottle-fed in- 
fants, however young they may be, are perhaps as susceptible to this disease 
as older children. After the first year of life scarlet fever increases in 
frequency up to the sixth year; the largest number of cases occur during 
the sixth and seventh years ; thereafter the disease diminishes until, at 
sixteen, it is rather infrequent and later becomes comparatively rare. The 
susceptibility of the individual child is an important and unexplained fac- 
tor; only about one-half of the children at the most susceptible age con- 
tract the disease even when they are brought into very close contact with 
the contagion. Scarlet fever is more prevalent during the winter than 
the summer months. The influence of cold weather in spreading this 
disease may be explained by the fact that it is during the winter months 



316 SCAELET FEYEE 

that children are housed together in school-rooms and in their homes,, thus 
producing conditions which favor the spread of contagious diseases, while 
during the summer months they live an outdoor life and are altogether 
under better hygienic surroundings. Minor, in his summary of the geo- 
graphical disposition of scarlet fever, apparently demonstrates that the 
disease thrives best in temperate climates. He found that in the West- 
ern Hemisphere scarlet fever occurred between the 10th and 30th degrees, 
N". latitude, and that above and below this were zones of comparative im- 
munity, in which the disease did not thrive for any length of time, even 
if imported. 

Exciting Causes. — A microorganism, as yet undiscovered, is the cause 
of scarlet fever. The lower animals so far as we know are not susceptible, 
and we have no evidence that the scarlet fever germ can multiply outside 
the human organism. There is evidence, however, that it may live and be 
transported in milk, the milk acting as a carrier rather than as a culture 
medium. The specific cause of scarlet fever is very tenacious of life, and 
may live for a long time under very adverse circumstances. It may cling 
to bedding, carpeting, hangings, clothing, linen, to the wall-paper and to 
apparently everything with which it comes in contact. It is especially diffi- 
cult to eradicate from infected rooms; many instances are on record where 
such rooms have been cleaned and apparently disinfected, and yet months 
later the disease has been contracted by children who have moved into 
them. The contagion of this disease lies especially in the muco-pus from 
the nose, throat, ears and in the scales of epithelium cast off by the der- 
matitis. The air immediately surrounding the patient is apparently not 
contaminated for more than four or five feet, and this contamination prob- 
ably results largely from the spray of mucus that is coughed into the sur- 
rounding air. Dried mucus and fine epithelial scales carrying contagion 
may be swept or otherwise thrown into the air, and perhaps be wafted for 
slight distances. Human intercourse, which brings the well in contact 
with the sick, is the great cause of the spread of this disease. In older 
children it frequently manifests itself as a scarlatinal angina; such chil- 
dren may never be seen by a doctor, and may continue to go to school, or 
to children's parties, or to mingle freely with the other children of the 
household, spreading the disease in their wake; this is perhaps the most 
common way in which the disease is disseminated. Children that are sup- 
posed to be convalescent, but who still have otitis media, rhinitis, or slight 
desquamation, are very frequently turned loose upon the community while 
they are still capable of spreading the infection. The poison may also be 
carried by letters, and by cats and dogs which pass from the sick to the 
well. Epidemics are also reported in which contaminated milk was sup- 
posed to be the carrier. Attendants and nurses may spread the disease in 
street-cars and homes to which they go after a night or day of nursing. 
The doctor, if he takes proper precautions, should not be a source of dan- 
ger. After many years of experience in hospital and private practice, I 
have never had a case in which there was the least suspicion that I had 



PATHOLOGY 317 

been the carrier of the contagion. The infection commonly enters through 
the mouth or nose and affects primarily the mucous membrane of the naso- 
pharynx. It may, however, enter surgical or other wounds, or it may, by 
the hand of the obstetrician, be carried into the vagina. These latter meth- 
ods of infection are now very rare. 

Period of Contagion. — Scarlet fever is contagious from the appearance 
of the first catarrhal symptoms in the throat. The most contagious period 
is during the first week, when the fever and throat symptoms are severe. 
With the subsidence of these symptoms the disease is less contagious, but 
with the beginning of desquamation it again becomes more contagious, and 
contagion probably exists as long as desquamation lasts, or as long as there 
is a mucopurulent discharge from the nose, ears, and throat. In all well- 
marked cases it is safe and proper to assume that the contagion lasts for at 
least six weeks, and during this time there should be a rigid quarantine. 
The proper care of the skin, the disinfection of the throat and general 
hygienic measures for destroying the contagion and preventing the con- 
tamination of the surroundings will diminish the period of conta- 
giousness. 

Pathology. — The specific organism of scarlet fever is unknown, but 
streptococci play a most important role in its pathology. These cocci, 
which are almost always found in the throat and often in the blood, have 
been believed by many writers to be the actual cause of this disease. Klein 
and Gordon described a streptococcus scarlatina and Kurth a streptococcus 
conglomeratus, these organisms differing slightly from the streptococcus 
pyogenes which has been so generally associated with the pathology of 
scarlet fever. The streptococci which have been found in the throat and 
blood of scarlet fever patients have no well-defined characteristics which 
differentiate them from other streptococci. The streptococcus pyogenes and 
the staphylococcus aureus and albus are more or less definitely associated 
with the destructive processes which accompany and follow scarlet fever. 
Hektoen found that the degree of streptococcemia in scarlet fever was 
closely related to the severity of the disease. In mild cases few streptococci 
were found in the blood ; in severe, and especially in complicated, cases they 
were found in larger numbers. They may, however, be absent from the 
blood in even fatal cases. Streptococci are also found in the urine and in 
the discharges from the nose, throat, and ears. Mallory describes certain 
protozoon-like bodies found in the skin of scarlet fever cases which are of 
interest, but their pathological and etiological importance has not yet been 
determined. Vipond isolated a bacillus with which he produced in monkeys 
a scarlet rash and fever. 

The lesions in scarlet fever are not characteristic; well-defined, acute 
dermatitis, ending in desquamation, is the most distinctive. The angina, 
which produces a marked congestion and inflammation of the tonsils, 
pharynx and soft palate, with a grayish-white exudation due to the action 
of cocci, is also commonly present. The other lesions on the part of the 
lungs, kidneys, joints, lymphatic glands, and cellular tissue are complica- 



318 SCAELET FEVEK 

tions due rather to the action of cocci than to the specific organism which 
produces scarlet fever. 

Period of Incubation. — The period of incubation has perhaps a wider 
range than in any of the other acute infections. According to McCollom, 
it varies from four to twenty days, the average period being ten to four- 
teen days. Most other writers name a shorter period of incubation, the 
average being six or seven days. A number of well-authenticated instances 
are on record where it has developed within twenty-four hours after ex- 
posure, and the evidence also seems to be conclusive that the incubation 
stage may be prolonged for fifteen or twenty days. 

Symptomatology. — Scarlet fever is a disease that presents the widest 
variations in its symptomatology, from a mild angina which may not be 
recognized to foudroyant cases where the toxemia is so intense that the 
patient's life is destroyed within twenty-four hours. The following de- 
scription represents a moderately severe case of typical scarlet fever; 
the variations from this type will be considered later. 

Onset. — A feeling of malaise, covering a period of one or two days, 
may precede the more characteristic symptoms, but in the great majority 
of cases the onset of the disease is marked by vomiting, headache, fever, 
and sore throat. This symptom group, which is more or less suggestive of 
scarlet fever, may be accompanied by a chill in older children or convul- 
sions in young children. Within the first twenty-four hours a scarlet rash 
commonly appears on the chest and neck, and gradually extends over the 
body. During the second week desquamation, the most characteristic of all 
the symptoms, makes its appearance. None of the above symptoms, how- 
ever, are absolutely characteristic, any of them may be absent, but in the 
great majority of cases the syndrome of scarlet fever made by the above 
symptoms is sufficiently distinct to make a diagnosis. The severity of the 
disease may be predicted in a measure by the suddenness and violence of 
its onset. 

Vomiting occurs in about 70 to 80 per cent, of the cases and commonly 
marks the onset of the disease. It may be repeated a number of times 
and then subside. Prolonged and continuous vomiting is not character- 
istic. When vomiting occurs late, after the other acute symptoms have 
subsided, it is a more serious symptom and may mean a beginning uremia. 
In young children a diarrhea may accompany the vomiting, but this symp- 
tom rarely persists longer than two days. 

Fever. — A rise in temperature immediately follows the vomiting. The 
fever commonly reaches its height by the end of the second day, but the 
maximum temperature may, in some cases, be found at the end of the first 
twenty-four hours; a temperature of 102 °F. indicates a mild infection, and 
105° F. or over, a severe one. Following the rapid rise in temperature of 
the first two days, the fever usually begins to subside, getting lower day 
by day until by the end of the week it may reach normal. It may, even 
in uncomplicated cases, last from twelve to fourteen days. There is noth- 
ing characteristic in the temperature curve of scarlet fever, and its value 



SYMPTOMATOLOGY 



319 



as a diagnostic sign depends largely upon its association with the other 
symptoms. A rise in the temperature, after it has been slowly falling for a 
number of days or after it has become normal, indicates some complication, 
such as adenitis or otitis. 



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SCAELET FEVER 



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but this high pulse rate, out of proportion to the temperaturej does not 



SYMPTOMATOLOGY 321 

necessarily mean an unfavorable prognosis; it is, however, a symptom of 
diagnostic value. 

Sore Throat. — The sore throat which is almost always present is, when 
taken in connection with the other symptoms, of great value in diagnosis. 
It manifests itself in four types : (a) Simple pharyngitis with swelling of 
the pillars of the fauces and tonsils; (b) more intense swelling and infiltra- 
tion of these tissues with grayish white deposits in and around the tonsillar 
crypts; (c) diphtheroid angina with intense infiltration of pharyngeal 
structures, associated with adenitis and cellulitis of the neck; (d) true 
diphtheria. In the early examination of the mouth in suspected scarlet 
fever cases, one may sometimes make out that the roof of the mouth is not 
only red and congested, but that it has also fine points of deeper redness 
scattered over it, which give it a punctate appearance. This enanthem 
when present is a valuable diagnostic sign. 

Other General Symptoms. — Cervical adenitis of the glands at the 
angle of the jaw occurs in the majority of cases. When the throat inflam- 
mation is severe, ulcerative and necrotic, the cervical lymph nodes are more 
seriously involved. These glands may enlarge, forming tumor masses bound 
together by. an inflammation of the cellular tissue which may result in a 
more or less board-like tumefaction. This condition is an ominous one; 
it may result in a dry necrosis, causing great destruction to the tissues of 
the neck and a subsequent general septicopyemia. This severe form of 
adenitis is to be considered rather as a complication than as a symptom 
of the disease, but even the milder cases may result in a suppurating 
adenitis, especially in tuberculous children. This process occurs more com- 
monly in children suffering from latent tuberculosis. 

The Tongue. — The appearance of the tongue is of more diagnostic 
value in scarlet fever than in any other general disease. In the beginning 
it is covered with a white coat through which small red papillae are seen to 
protrude; after two or three days the white coating disappears, leaving it 
red, but the papillae still stand out prominently as little dots of redder 
hue; these are to be seen along the edges and especially on the tip of the 
tongue, and give to it a strawberry appearance, hence the term "straw- 
berry tongue," first described by Flint. 

Eruption. — The rash of scarlet fever generally makes its appearance 
on the neck or chest within the first twenty-four or thirt}^-six hours; it 
may, however, be delayed until the third or fourth day, and in rare in- 
stances even as late as the sixth day, and is usually accompanied by more 
or less itching. The eruption, within two days after its appearance, spreads 
to all parts of the body. In the beginning it has a punctate appearance 
produced by small red points closely approximated and scattered in patches 
over the skin, which coalesce, and in the course of twenty-four hours the 
punctate appearance may be lost in a uniform scarlet eruption which dis- 
appears on pressure. The rash takes on a deeper scarlet hue and reaches 
its maximum of redness in two days; it then gradually fades, entirely dis- 
appearing in from four to seven days. The face may remain free or show 



322 SCARLET FEVER 

only slight signs of the eruption, but even when the skin of the face is 
covered with the scarlet rash there is a peculiar pallor about the mouth, 
and herpes may also be present. The rash is more intense in those regions 
of the body where the folds of the skin are brought into juxtaposition, 
such as the axilla, the inguinal region, the under-surface of the elbow and 
knee joints, the folds of the buttocks, and approximated surfaces of the 
thighs. The rash of scarlet fever varies greatly in different cases; it may 
not be present at all, it may last but a few hours, it may appear in but 
a few punctate patches on the parts of the body where the skin is in 
juxtaposition, or it may present the typical appearance just described and 
be followed by miliaria or urticaria. In malignant cases it may be hemor- 
rhagic. 

Desquamation, which is perhaps the most characteristic symptom of 
scarlet fever, commences about the seventh day; in severe cases it may 
begin earlier, in mild cases later. It continues from three to six weeks, or 
in severe cases longer. The character and extent of the desquamation 
depend largely upon the severity of the dermatitis; if this be severe and 
marked by a uniformly brilliant scarlet eruption, the desquamation that 
follows is more extensive and the epithelium is peeled off in larger flakes. 
In the milder cases it may be almost or quite absent; in such instances it 
should be sought for especially in the axillary and inguinal regions, and 
under the finger nails. Desquamation begins, as a rule, on the neck, chest, 
and fingers and spreads to other portions of the body, the skin of the feet 
being the last to peel. It may be fine and scaly, like the furfuraceous 
desquamation of measles; it is, however, more commonly flaky or lamellar 
in character. The older the child, and the more hardened and tougher 
the skin, the more marked the desquamation. On the hands and feet the 
epidermis may be peeled off in large pieces; entire casts of the fingers and 
hands have been removed in some instances. Secondary desquamation 
may occur, especially in the more severe cases. 

Urine. — The urine should be examined frequently from the onset of 
the disease until desquamation has ceased. A trace of albumin is present 
in from 10 to 15 per cent, of the cases; this slight albuminuria, even 
when accompanied by a few hyalin casts, is not an ominous symptom. It 
may be a simple febrile or toxic albuminuria, more commonly present in 
this disease than in other fevers, because the skin is largely put out of 
action and the kidneys are therefore called upon to do extra work. The 
presence of albumin, however, associated with granular and epithelial casts, 
is a much more serious matter, and indicates the onset of acute nephritis. 
The kidney complications of scarlet fever are commonly post-scarlatinal, 
occurring after the acute symptoms have subsided. This subject is con- 
sidered in the chapter on Acute Nephritis. 

Blood. — There is a slight secondary anemia with a moderate reduc- 
tion of both hemoglobin and red blood corpuscles. Between the second and 
eighth day there is a leukocytosis of eighteen to forty thousand; the poly- 
morphonuclear leukocytes are relatively and absolutely increased early in 



IRREGULAR CLINICAL TYPES 323 

the disease, and rapidly diminish as the fever and toxemia subside. The 
mononuclears are relatively and absolutely increased in the later stages. 
The eosinophiles are increased as the toxemia subsides. 

Recurrence and Relapse. — One attack of scarlet fever confers perma- 
nent immunity. This is a rule which has but few exceptions, although 
very rarely second attacks may occur. A relapse, while also rare, is more 
common than a recurrence from reinfection ; it may occur during the third 
or fourth week and produce the symptom group in a milder form. A 
return of the eruption within two or three days after its disappearance is 
not to be confounded with a true relapse, since its return at this time is 
usually of little moment, and it disappears shortly without being accom- 
panied by other untoward symptoms. 

Irregular Clinical Types. — From the ordinary type above described 
there are a number of important clinical variations. 

Mild Type. — Scarlet fever may manifest itself in a form so mild that 
the character of the disease may not be suspected and the infected child 
may unintentionally spread the disease broadcast. Vomiting may or may 
not be present, there is a slight elevation of temperature, which soon falls 
to normal, and the patient is thought to have an ordinary tonsillitis or 
pharyngitis. The true nature of the infection may be determined by pre- 
vious or subsequent cases of scarlet fever in the same family or by the ap- 
pearance of a slight eruption, followed by furfuraceous desquamation in 
the axilla or groins. The enanthem or fine punctate eruption on the roof 
of the mouth may be present, and should always be looked for in every 
case of sore throat or scarlatinaform eruption. 

Malignant or Fulminating Type. — Cases of this character are very 
uncommon. Within the course of a few hours the child may be so over- 
whelmed with the poison that the hopelessness of the case is apparent. 
In the most severe cases death may occur within two days; as a rule, 
however, the disease lasts from three to six days. The onset is marked by 
severe nervous symptoms which may suggest meningeal involvement; con- 
vulsions, delirium and coma may follow each other in quick succession. 
The child tosses about in bed and cannot be quieted; the fever from the 
onset is high, the pulse rapid, and death commonly results either from 
acute cardiac dilatation or from slow cardiac failure. If the patient lives 
long enough a severe sore throat and scarlet eruption appear; in some in- 
stances the rash is hemorrhagic. In the most violent of these cases the 
diagnosis is difficult and at times impossible, as the patient does not live 
long enough to develop typical symptoms. Between the mild and malignant 
types we may have every grade of severity. In the same epidemic we may 
see both mild and malignant cases. 

Septic Type. — Accurately speaking, this is a complication rather than 
a type of scarlet fever, but as previously noted, the role played by septic 
organisms in producing the symptom-complex of scarlet fever is very great, 
and in a large percentage of the cases the septicemia or septicopyemia 
presents such a distinct symptom-complex that it has come to be considered 



324 SCAELET FEVER 

as a type of this disease. The onset is that of severe scarlet fever, but as 
the fever begins to subside a slight or sudden rise in the temperature 
occurs. This secondary rise is a most significant symptom, and is usually 
accompanied by an enlargement of the cervical lymphatics. Upon these 
two symptoms alone one is justified in assuming that the time has come 
to use our most energetic therapeutic measures for controlling septicemia. 
If the condition is not controlled, the temperature continues high with 
marked variations and may run for many weeks. At times it is not unlike 
the temperature of typhoid fever or of general miliary tuberculosis. The 
throat symptoms and all other symptoms of scarlet fever may gradually 
disappear, leaving the symptom-complex of a septicopyemia. Suppuration 
of the lymphatic glands of the neck may occur and a septic pericarditis, 
arthritis, pleuritis or bronchopneumonia may develop. 

Complications. — Otitis media is a very common complication. It oc- 
curs in from 15 to 20 per cent, of hospital cases, but is less in private 
practice; it is a sequel of the pharyngitis of this disease and is more com- 
mon in tuberculous children. In the treatment of every case of scarlet 
fever, and especially in those with tuberculous family histories, the pos- 
sibility of the development of otitis media should constantly be kept in 
mind and a secondary rise in temperature should always lead to a careful 
examination of the ear. In infants, apparently convalescent from scarlet 
fever, this complication may be suspected if the child suddenly becomes 
restless, sleepless and cries with pain. 

Ulcerative and gangrenous angina, which may result in the destruction 
of the tissues of the throat, is much to be dreaded but is fortunately rare. 

The septic arthritis, which may occur as a part of the symptom-complex 
of the septicopyemia of scarlet fever, is multiple, commonly involves the 
large joints and is sometimes associated with purpura. There is, however, 
another form of scarlatinal arthritis, producing an acute inflamma- 
tion of the synovial membranes, not associated with pus formation. This 
condition is spoken of as scarlatinal rheumatism. It is a rare but 
very well defined symptom group; the wrist and finger joints are most 
commonly involved, but some of the large joints of the extremities 
may also be affected. It produces fever, with redness, tenderness and 
swelling of the joints, and it may produce pericarditis and true endo- 
carditis, leaving the valves of the heart permanently injured. Both 
the arthritic and cardiac symptoms, however, are on the whole much less 
severe than they are in true articular rheumatism. Salicylic acid appar- 
ently relieves the pain and reduces the fever which occurs in this condi- 
tion; whether or not it is true rheumatic fever, complicating scarlet fever, 
or a manifestation of the scarlatinal toxemia is not altogether clear. The 
latter hypothesis is more rational. 

Nephritis is one of the most common and serious complications of 
scarlet fever. In the majority of instances it is a post-scarlatinal lesion 
and is, therefore, to be carefully looked for during and after the third week. 
It may be made manifest by a slight puffing of the eyelids, severe head- 



PKOGNOSIS 325 

ache, sudden rise of temperature, nausea or vomiting, but the diagnosis is 
made by the finding of albumin and casts in the urine, or possibly by the 
sudden development of convulsions and other uremic symptoms. 

Cardiac murmurs are common during the height of the disease, but true 
endocarditis is rare. Myocardial degeneration of greater or less degree is 
very common. 

Nervous lesions may occur. In severe cases meningitis, hemiplegia, 
chorea, and symmetrical gangrene are occasionally seen. 

Diagnosis. — There is perhaps no disease in which it is more important 
to make an accurate diagnosis than in scarlet fever. The responsibility 
of the physician is here very great. On the one hand if he comes in con- 
tact with a mild case and fails to make the diagnosis great damage may be 
done by spreading the disease broadcast. On the other hand, if he comes in 
contact with one of the numerous rashes that so closely resemble scarlet fe- 
ver, and condemns the patient as well as the entire household to six long 
weeks of rigid quarantine, he has thereby done great injustice and caused 
great inconvenience. Since in many instances it is absolutely impossible for 
the physician to make the diagnosis it is his duty to quarantine all sus- 
picious cases until the question has been fully settled. In the ordinary 
case the diagnosis is easily made by the sudden onset of vomiting, sore 
throat and fever followed by the rash, the "strawberry tongue" and later 
the desquamation. Upon one point in the differential diagnosis I wish 
especially to insist, and that is upon the early appearance of the more or 
less typical enanthem. The roof of the mouth is red and congested, and 
over this red surface fine points of more scarlet hue are scattered in close 
juxtaposition. When this condition can be made out it is of great value as 
an early diagnostic symptom in distinguishing scarlet fever from measles 
and rubella. 

The erythematous rash of influenza associated with fever, sore throat 
and gastric disturbance produces a clinical picture which can only be 
differentiated from scarlet fever by the development of further symptoms. 
Eashes resembling scarlet fever may also result from digestive disturbances, 
sepsis and from drugs such as antipyrin, quinin and atropin. Acute exfo- 
liating dermatitis and the serum rashes following the use of diphtheria 
antitoxin are often difficult of differentiation from scarlet fever. 

Prognosis. — Age is one of the most important determining factors in 
the prognosis of scarlet fever. The younger the patient the more fatal 
the disease. From a study of 5,000 cases of scarlet fever, treated at the 
South Department of the Boston City Hospital, McCollom found the 
death rate to be over 33 per cent, in children under one year of age. This 
mortality rapidly decreased so that between the sixth and seventh year it 
was about 7 per cent. From this time on there was a very gradual de- 
crease in the death rate. The accompanying chart graphically illustrates 
the increasing powers of resistance which age gives to this disease. 

The character of the epidemic is also important in determining the 
death rate. Some epidemics are characterized by unusually severe cases 



326 



SCAKLET FEVEK 



with great mortality. Others are mild and the mortality is correspondingly 
low. The mortality, especially during the first two or three years of life, 
is much lower in private than it is in hospital practice. This is not only 
due to the early medical attention which private cases receive, but also 
to the fact that these children are much better nourished and have, on 
the whole, greater powers of resistance than the malnourished weaklings 
that find their way to public hospitals. The general mortality of scarlet 
fever at all ages is variously estimated by different writers; it is on the 



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Fig. 54.— Mortality by Age in 5,000 Cases of Scarlet Fever. (McCollom.) 



average about 12 per cent. In the individual child, apart from its age 
and the severity of the prevailing epidemic, the severity of the onset is 
the most important prognostic factor. High temperature, convulsions, 
profound nervous symptoms, and a bad sore throat with extensive involve- 
ment of the cervical lymph nodes indicate that the child's life is in peril. 
Dangers may beset the child from the onset of the disease until the com- 
pletion of its convalescence. In the beginning the danger is that it may 
be overwhelmed by the violence of the toxemia. Toward the end of the 



PEOPHYLAXIS 327 

first week, violent throat symptoms with a beginning septicemia may 
foretell an unfavorable termination, and throughout its convalescence, 
nephritis, bronchopneumonia and a general septicopyemia may place 
the child's life in peril. With all of these unforeseen dangers the prog- 
nosis in any individual case is uncertain, even though the present condi- 
tions are favorable. 

Prophylaxis. — The prophylactic treatment of scarlet fever is perhaps 
more important than that of any other disease. The most important ob- 
ject to be obtained is the absolute isolation of the sick child from everyone 
except the necessary attendants. This is a matter not only of the greatest 
difficulty, but, in the majority of instances, it is absolutely impossible. 
Among the children of the poor, the patient should be removed to a con- 
tagious-disease hospital. Among the rich, the problem of isolation is 
not so difficult. Among the middle class, the question of expense, which 
absolute isolation entails, is a very serious hindrance to the proper prophy- 
lactic treatment of scarlet fever. There are, however, certain recognized 
principles in the home treatment which the physician should endeavor to 
follow, conforming as closly to the ideal conditions as circumstances will 
allow. The following details apply not only to scarlet fever but to diph- 
theria and smallpox as well. 

As soon as scarlet fever is suspected the two most available rooms in 
the house, for isolation purposes, should be selected; one for the patient 
and one for the nurse off duty. All rugs, carpets, hangings, and un- 
necessary articles of furniture and clothing should be removed, and the 
rooms furnished with iron beds and with such chairs and tables as can 
be easily cleaned. A day and night nurse should be installed, and they 
should have entire charge of the rooms and the patient. The fetching and 
carrying of food, clothing and other things to and from the room should 
be done with such care that other members of the household will not be 
infected. The physician on entering the room should put on a fresh 
white gown and cap, and should remain in contact with the patient as 
short a time as possible, and on his exit should carefully cleanse and dis- 
infect his hands, his stethoscope, or any other instrument he may have 
used. The nurse should be directed to destroy the excretions from the 
throat and nose, either by burning or by placing them in a solution 
of bichlorid of mercury. There is no danger that the poison of scarlet 
fever will permeate the air and contaminate halls and neighboring rooms ; 
for this reason isolation, when intelligently carried out, will protect the 
other members of the household from the disease. When desquamation 
commences, inunctions with oil or ointments will not only be a comfort 
to the patient, but will prevent the scattering of the scales of skin through- 
out the room; the frequent use of inunctions is therefore a most important 
prophylactic measure. The isolation of the child should be rigidly kept up 
until desquamation and all discharges from the nose and throat cease; in 
the average case this covers a period of six weeks. When the quarantine is 
raised the patient's body should be thoroughly washed with soap and hot 



328 SCARLET FEVER 

water, and his hair and nails carefully cleansed before he is permitted 
to leave the room and mingle with the household. 

The sick rooms should be fumigated with formaldehyde. McCollom 
says : "The simplest and also an effectual method of generating formalde- 
hyde is that adopted by the Maine Board of Health, which consists of mix- 
ing potassium permanganate with a 40-per-cent. solution of formalin. The 
potassium permanganate should be the commercial and not the chemically 
pure. ISTo special apparatus is required. An ordinary tin dish with flaring 
sides can be used. The quantity of permanganate for each pint of formalin 
is 6I/2 ounces. It is very important that the permanganate be put in the 
dish first, and then the formalin solution poured over it. It is taken for 
granted that the room has been tightly sealed. As soon as the formalin 
is placed in the receptacle a rapid exit must be made, because the gas is 
generated very quickly. The room should remain closed for twenty-four 
hours and then be thoroughly aired. The quantity of the 40-per-cent. solu- 
tion of formalin and of the potassium permanganate to disinfect 500 cubic 
feet of space is 1 pint of the former and 6% ounces of the latter." Follow- 
ing disinfection, the woodwork should be washed with soap and water and 
then rubbed down with a 1 : 1,000 solution of bichlorid of mercury. The 
wall paper should be cleaned or removed. . All books and toys should be 
destroyed and the bed linen should be treated, as throughout the course 
of the disease, by placing it first in a bichlorid solution and then subjecting 
it to boiling. The mattress should be burned. Where this is not expe- 
dient, as in hospitals, it should be disinfected by steam. Following the 
cleansing of the room, it should a second time be fumigated with formal- 
dehyde. 

School inspection by health boards is one of the most valuable prophy- 
lactic measures. Where this is systematically carried out at least once a 
week, a large number of children will be found with throat and nose dis- 
ease, or with other evidences of illness which justify their being sent home 
and kept under proper medical supervision until they have recovered. In 
our large cities, where school inspection is now being successfully carried 
out, there is little doubt but that many children with scarlatinal angina are 
prevented from mingling and spreading the disease among other children. 
Clinical reports now indicate that the use of streptococcus vaccines may be 
a valuable prophylactic measure. 

Treatment. — There is no specific treatment for this disease, and the 
physician should ever keep in mind that it is self-limited and in the great 
majority of instances runs its course to a successful termination. These 
facts being understood, it is most important that medication should be 
given only when medicines are indicated, and that the symptomatic treat- 
ment should not be overdone. 

The patient should be put to bed and kept there for a week or ten days 
after all acute symptoms have subsided; this materially diminishes the 
danger of renal and other complications. The sick room should be well 
ventilated, at a temperature between 65° and 70° F. The bed and body 



TREATMENT 329 

linen should be frequently changed, and the bed covering should be com- 
paratively light. It is most important that scarlet-fever cases should not 
be kept overwarm with bed clothing and by living in superheated rooms. 
During the first forty-eight hours the bowels should be moved with calomel, 
followed by some saline laxative, and thereafter kept open, if necessary, by 
the use of some mild cathartic, such as cascara. 

Dietetic Treatment. — During the first days barley water and mutton 
broth may be given. With the subsidence of the vomiting and the quieting 
of the stomach the milk diet is begun. Milk in some form should be al- 
most the exclusive diet for the next three weeks; one or two quarts, de- 
pending upon the age of the child, may be taken within twenty-four hours. 
Milk is of special value in that it serves nutritional purposes, is easy of 
digestion, acts as a diuretic and throws very little work upon the already 
overtaxed kidneys. It will sometimes tax the ingenuity of the physician 
to maintain the milk diet throughout this period. . The term milk diet, as 
here used, includes all of the artificial milk foods, ice cream and butter- 
milk. The milk may be flavored with cocoa or vanilla, mixed with cereal 
decoctions or made into milk-soups. Certain drinks, such as lemonade 
and orangeade, never mixed with albumin water, may be given. During 
convalescence, after the third week, other foods may be used, such as bread, 
stewed fruits, baked apples, rice pudding, cereals, thick soups, and, later, 
potatoes, vegetables, fish and chicken may be added. 

Hydrotherapy is a most important part of the treatment. In all 
cases, especially where the temperature runs high, baths are not only a 
valuable therapeutic measure but they add greatly to the comfort of the 
patient. In the milder cases sponge baths, with water at a temperature 
between 70° and 80° F., should be given twice a day. In severe cases tub 
baths at a temperature of 70° F. or moderately cold packs given every four 
or six hours are more effective. In connection with these baths, an ice-cap 
should be applied to the head, but this application should not be continuous, 
except in the malignant type of the disease where the fever is high and the 
nervous symptoms are profound. It should be remembered, in applying 
the various measures here recommended, that all children do not respond 
kindly to cold baths; this is especially true of infants. On the whole, it 
may be said that the older the child the more effective and the more sat- 
isfactory will be the cold-bath treatment. But in any given instance, if 
the bath produces unfavorable symptoms, such as great prostration, weak 
heart, cyanosis, and cold extremities, it is to be either discontinued or so 
modified as to get the good without producing the bad results. The or- 
dinary coal-tar antipyretics should not be used for the control of the tem- 
perature or the nervous symptoms. 

Stimulants. — In malignant cases stimulants are necessary to counter- 
act the severe onslaught of the toxins on the nervous system and the heart. 
For this purpose whiskey, brandy, or champagne may be freely given during 
the early days of the treatment. After the poison has spent its force and 
the nervous system has commenced to recover from its effects alcohol is. 



330 SCAELBT FEVEE 

no longer indicated and finds no place in the treatment of scarlet fever ; its 
use after this period may be injurious to the kidney. Other stimulants, 
however, may be used in connection with the alcohol and may be continued 
throughout the course of the disease; the most valuable of these are stro- 
phanthus and digitalis. They are especially indicated in severe and pro- 
longed cases of scarlet fever, with rapid and weak heart. Strophanthus is 
especially valuable in very young children and digitalis in older children, 
and both of these drugs should be combined with essence of pepsin or some 
other palatable vehicle which will protect the digestive organs of the child. 
Strychnin in 1/150 to 1/200-grain doses is another valuable stimulant, 
acting especially on the respiratory centers, and may be continued through- 
out the course of the disease. In extreme cases, where collapse threatens, 
salt solution and caffein sodium benzoate may be given in the same dose 
and manner as directed under Diphtheria. 

Inunctions are a part of the routine treatment of scarlet fever. The 
child should be anointed twice a day with oil, cocoa-butter, lanolin, cold 
cream, or lard. They prevent the scales of skin from being scattered about 
and make the patient more comfortable by allaying the itching and irri- 
tation of the skin. Seibert recommends the use of a 10-per-cent. icthyol 
lanolin ointment. Other writers advise that boric acid and carbolic acid be 
combined with the ointments above named. The general consensus of 
opinion is that the value of this treatment depends upon the soothing rather 
than the antiseptic action of the ointment. 

The systematic treatment of the nose and throat is important; for 
this purpose an atomizer may be used containing 1 ounce of liquid albolin, 
combined with 10 minims of oil of eucalyptus and 3 grains of menthol, or 
some alkaline antiseptic solution. When the angina is severe, mild sa- 
line antiseptic solutions may be injected through the nose, coming out 
through the pharynx, in the manner described in the chapter on Therapeu- 
tics of Infancy and Childhood, and the throat should be swabbed alternately 
every two or three hours with a 1/1,000 bichlorid of mercury solution and 
a 30 per cent, argyrol solution. The object of this treatment is to minimize 
the systemic intoxication, to modify the local inflammatory conditions, and 
to prevent internal ear complications. In severe gangrenous inflammations 
of the throat strong nitrate of silver solutions and even the thermocautery 
have been recommended. Where diphtheria complicates scarlet fever diph- 
theria antitoxin should be given. 

With the onset of septicemic symptoms one should begin the use of 
antistreptococcic serum made from cocci taken from a case of scarlet fever; 
from 100 to 200 c. c. should be given every eight to twelve hours for three 
or four days; the size of the dose will depend upon the age of the patient. 
In my experience this serum, if given at the proper time, is a life-saving 
measure of great importance. Escherich and Moser, using Moser's serum, 
greatly reduced the mortality of scarlet fever in the Annakinderspital at 
Vienna. Fedinski and Nicoll have also used antistreptococcic serum with 
very favorable results. Collargolum is a remedy of great value in the 



TKEATMENT 331 

treatment of the septicopyemia of scarlet fever. It may be given in the 
form of rectal suppositories or perhaps better by inunctions with unguen- 
tum Crede. This latter preparation I have used very extensively for years, 
and I believe that when properly administered it is of great value in pre- 
venting the development of general septicemia. The technique for its use 
is as follows: The whole upper portion of the child's body is carefully 
cleansed with soap and water, and the skin is then made hot by the ap- 
plication of warm fomentations. One-half ounce of unguentum Crede is 
then slowly and carefully rubbed into the upper portion of the child's body 
over the neck, chest, and axillae, being careful not to injure the inflamed 
lymph nodes. This should be done twice a day for three or four 
days. The object of this application is to rub the silver ointment through 
the skin into the lymphatics and not simply to make an applica- 
tion over the enlarged lymph nodes. In the child this ointment is very 
readily taken up by the lymphatics and acts as a very potent lymphatic 
antiseptic. 

The treatment of adenitis, in addition to the measures above outlined, 
may demand the local application of ice; light ice-bags applied intermit- 
tently exercise a favorable influence, especially in the early stages of the 
inflammation. Forchheimer recommends that pressure be applied to these 
glands by the application of flexible collodium; 49 parts of collodium to 1 
part of castor-oil. If suppuration occurs, poultices are not only grateful, 
but hasten the breaking down of the gland, which is then to be incised with 
proper surgical precautions. 

Otitis Media. — Scarlet fever is one of the most common causes of 
deafness. In every case, especially if there be a tuberculous family history, 
the physician should always keep in mind the fact that otitis media may 
occur and may not only cause loss of hearing but may threaten the- life of 
the child by producing a mastoiditis. The ear should, therefore, be fre- 
quently examined throughout the course of this disease, and symptoms 
pointing to this complication should be constantly watched for. An early 
incision of the drum membrane may check the inflammation and prevent 
the involvement of the mastoid. The ear should then be carefully washed 
out twice a day with a boric-acid solution and should be carefully dried and 
some powdered boric acid dropped into the meatus, which is then lightly 
plugged with a pencil of dry cotton; this treatment should be continued 
from day to day. If there be the slightest tenderness over the mastoid, an 
ice-bag should be applied to this region, and the application of leeches may 
also be of value. If, however, the mastoid tenderness does not subside, and 
the septic temperature continues, the radical mastoid operation should be 
performed. 

Scarlatinal rheumatism should be treated in the same manner as 
acute rheumatic fever. The joints should be kept warm by wrapping them 
in flannels or cottons, and salicylates, such as aspirin, should be given to 
relieve the fever and pain. If the symptoms do not respond quickly to the 
salicylate treatment it is to be discontinued, as there is some difference 



332 MEASLES, RUBELLA, AND ERYTHEMA INFECTIOSUM 

of opinion as to whether the continued use of salicylic acid in this disease 
may not increase the dangers of nephritis. 

Nephritis. — In every case of scarlet fever the urine should be exam- 
ined daily for the onset of this complication, and if nephritis develops, hot 
baths, saline cathartics, a milk diet and the other treatment outlined under 
Acute Nephritis are to be carefully carried out. 

Convalescence. — Scarlet fever, especially in tuberculous children, leaves 
the patient more or less anemic, with enlarged lymphatic glands and pos- 
sibly with an otitis media. Under such conditions the organic iron prepara- 
tions, combined with malt and used in connection with or alternating with 
cod-liver oil, are of great value. It should also be remembered that following 
severe cases of scarlet fever some months are required for the heart to re- 
cover its normal tone, and in those cases where the rapid pulse continues 
the child should lead an outdoor life, but it should be carefully supervised 
as to the amount of exercise it takes. 

Septic rhinitis, otitis media and other septic processes following scarlet 
fever may be successfully treated by autogenous vaccines. Kolmer and 
Weston have used vaccines very successfully in the treatment of septic 
rhinitis, and, since they found that the staphylococcus aureus was the cause 
of this condition in 89 per cent, of the cases which they examined, they 
recommended the use of the stock vaccine of this organism when it is not 
possible to obtain an autogenous vaccine. The initial dose of this vaccine 
is 50,000,000, gradually increased to 100,000,000 dead staphylococci. 



CHAPTER XL 

MEASLES, KUBELLA, AND EEYTHEMA INFECTIOSUM 

MEASLES 

Measles is an acute infectious disease characterized by fever, catarrhal 
symptoms, an enanthem and an exanthem. 

Etiology. — The specific cause of measles has not been discovered. Gold- 
berg and Anderson produced the disease in monkeys by inoculating them 
with the blood of a measles patient. The infective microorganism multi- 
plies rapidly in, and is readily disseminated from, the human organism. It 
does not, however, develop in other organisms or in outside culture media. 
Measles is more contagious, and is desseminated more rapidly in a suscep- 
tible community than any other acute infection, smallpox and influenza pos- 
sibly excepted. Its spread, however, depends in a large degree upon rather 
close human intercourse ; that is to say, by the well coming in contact with 
the sick in homes, schools and public gatherings. Notwithstanding the ex- 
treme contagiousness of this disease, it is not readily carried from the sick 
to the well by a third party, nor is the contagion in any other manner very 
readily carried long distances. It may, however, be disseminated through 



MEASLES 333 

the air of the room, and it is a recognized fact that there is greater diffi- 
culty in protecting other susceptible individuals in the same household by 
rigid quarantine than there is in scarlet fever or diphtheria. The conta- 
gion of this disease, unlike that of scarlet fever or diphtheria, has a short 
life outside of the human organism, so that the room recently occupied by 
a measles patient soon purines itself. Measles is a world-wide disease. It 
is more prevalent during cold weather because of the closer indoor human 
intercourse during this season. 

Nursing infants under six months of age are practically immune, but 
thereafter the susceptibility increases until, at the end of the first year 
of life, measles is not uncommon. The age of greatest susceptibility is 
between three and seven. During this period perhaps 90 per cent, of all 
children exposed contract the disease. This great susceptibility and the 
extraordinary contagiousness are the reasons why such a small percentage 
of the population escapes. Susceptibility diminishes very slightly with age. 
The chief reason why measles is largely a disease of childhood is because 
most adults have been rendered immune by an attack in early life. In 
large cities extensive epidemics recur every two or three years; this is due 
to the fact that in this time large numbers of children have grown up to 
the susceptible age since the last epidemic. 

Immunity. — Natural immunity is very rare; perhaps not more than 
10 per cent, escape. A permanent and lasting immunity is conferred by 
an attack of measles. While second and even third attacks have been ob- 
served in the same individual, it is rare indeed to find instances where this 
acquired immunity does not protect throughout life. This protection is 
more marked in measles than in any other of the acute infections. 

Period of Contagion. — Measles is contagious from the beginning of 
the catarrhal stage until the end of desquamation. It is most contagious 
during the height of the fever and during the stage of eruption, but is 
generally spread by patients in the catarrhal stage, before the diagnosis 
has been made and the quarantine instituted. With the fall of the fever 
and the disappearance of the rash the contagion gradually diminishes, but 
probably lasts through desquamation. Ten days or two weeks later all 
contagion has disappeared, even though the sick room and belongings of 
the patient have not been disinfected. 

Pathology. — Measles is rarely a direct cause of death. It has, however, 
a comparatively large mortality, due to complicating conditions, such as 
enteritis, pneumonia, tuberculosis and, rarely, nephritis. Enterocolitis and 
pneumonia are especially dangerous in young children. The pathological 
changes belonging to measles proper are hyperemia of the skin and ca- 
tarrhal inflammation of the mucous membranes of the respiratory passages 
and eyes. Other mucous membranes may also be affected. 

Incubation Period. — This has been definitely established. The catarrhal 
symptoms occur in ten or eleven days, and the skin eruption in fourteen 
days from the date of exposure to the contagion. The period of incubation 
is marked by no characteristic symptoms; certain transitory rashes, such as 



334 MEASLES, RUBELLA, AND ERYTHEMA INFECTIOSUM 

erythema and urticaria, may appear, but they are of little importance, and 
the child remains well until the catarrhal symptoms begin to develop on or 
about the eleventh day. 

Symptomatology.- — The symptoms may be conveniently divided into 
three stages : the enanthem stage, the exanthem stage and the stage of con- 
valescence. 

Enanthem Stage. — This is the stage of invasion and commonly lasts 
three days. Previous to the discovery of the characteristic enanthem of 
this disease by Koplik, a diagnosis during this stage was difficult and un- 
certain. The onset is usually marked with fever, drowsiness and catarrhal 
symptoms on the part of the eyes and respiratory passages. Irritation of 
the throat, coryza, sneezing and a beginning catarrhal irritation of the 
conjunctiva are important symptoms. Lacrimation and photophobia are 
commonly present, the patient shielding his eyes from the light. The 
cough which accompanies the bronchial catarrh is dry, harsh, and par- 
oxysmal, and if the larynx be especially involved in the catarrhal process 
it is hoarse and croupy. These catarrhal symptoms increase in severity, 
the child becomes more languid, irritable and uncomfortable, and the fever, 
which is commonly remittent during this stage, increases from day to day. 
The appearance of the above symptom group, while not at all pathogno- 
monic, should always suggest to the physician the possibility of measles. If 
to this there be added the history of exposure to contagion, a probable 
diagnosis can be made, but an early positive diagnosis can, as a rule, only 
be made by examining the mucous membrane of the mouth and there 
observing the characteristic enanthem. This is best described by Koplik 
himself : "On looking at the mucous membrane lining the cheeks, in strong 
sunlight, a very characteristic eruption of irregular stellate or round rose- 
colored spots is seen. In the center of each spot there is a bluish-white 
speck. This appearance of a bluish-white speck on a rose-colored back- 
ground is pathognomonic of the onset of measles. The speck is sometimes 
so minute that strong sunlight is necessary to render it visible. The num- 
ber of specks at the outset may be less than half a dozen. In a short time 
they become more numerous and the rose-colored spots become confluent 
so that there are diffusely red patches of buccal mucous membranes, 
studded with bluish-white specks. The specks rarely or never become con- 
fluent; their color does not resemble that of sprue, nor are they as coarse 
as sprue accumulations. They are seen on the inner surface of the lips 
and are sometimes well marked on the buccal mucous membrane adjacent 
to the gums of the upper molar teeth. If the finger is passed over the 
mucous membrane they are felt to be raised and firmly adherent. They 
can be rubbed off by force, or picked off with forceps. As the exanthema 
spreads, the enanthema of the buccal mucous membrane becomes diffuse. 
When the exanthem is at its height and during efflorescence the eruption 
on the mucous membrane begins to lose its characteristics. The bluish- 
white specks are washed away by the buccal secretions and leave the mucous 
membrane diffusely reddened and raw." Koplik's observations as to the 



PLATE III. 





The Buccal Eruption of Measles (Koplik's Spots). (Holt). 

A. This represents the earliest stage; the spots are few, rather large, widely sepa- 
rated, and usually show a distinct areola; the mucous membrane is normal in color. 

B. The later appearance and that most frequently seen. 

Near the center of the field the spots are closer together, although still remaining 
individually distinct; the mucous membrane is somewhat congested. At the margin 
of the field they are fainter and lack the areola, representing a still later period, such 
as is seen before they disappear altogether, although in some cases they are not more 
distinct than this at any stage. 



MEASLES 335 

diagnostic value and prevalence of this enanthem have been confirmed by 
the medical world. "Koplik spots" occur before the appearance of the skin 
eruption in 90 per cent, of the cases. They may usually be seen from 
twenty-four to thirty-six hours before the exanthem appears and in some 
cases earlier. In a few instances they are delayed and are coincident with 
the skin eruption. It is important to remember that they cannot be seen 
by artificial light, strong sunlight being necessary for their detection. Prior 
to the appearance of Koplik's enanthem, or coincident with it, there may 
be seen on the velum of the palate and on the mucous membrane of the 
hard palate a diffused redness, with deeper red or rose-colored spots, in 
the center of which are small white follicles. This enanthem was described 
by various writers before Koplik made his observations, but they are not 
so characteristic and have not the diagnostic value of "Koplik spots." 

Exanthem Stage. — The fever, which, during the first three days of 
the disease, gradually increases in severity, reaches its height and con- 
tinues high during the stage of eruption, not beginning to decline until the 
exanthem is fully developed. With the fading of the exanthem the tem- 
perature falls rapidly. 

The exanthem or skin eruption, which is the characteristic symptom 
of this stage, commonly begins about the fourth day of the disease upon 
the face or behind the ears ; it may first appear upon the back. It then 
spreads, gradually involving the neck, chest, back, arms, lower portion of 
the body, thighs, and lastly the hands and feet. Two or three days are 
usually required for the eruption to reach its height, but in some instances 
it may spread rapidly, covering the body within twenty-four hours, and 
in others it may be delayed, not reaching its maximum for four or five 
days. It appears first in the form of small red papules, about the size 
of a pin's head. These red points, which may be readily felt, are quickly 
surrounded by a small red zone, producing the typical macule of measles, 
which is round, oval or crescent shaped, and is still separated from neigh- 
boring spots by faint areas of normal skin. These macules grow darker in 
color and still further coalesce, forming darker patches, but in these larger 
zones of redness the small, dark-red, hard papules which formed the nucleus 
of the original eruption may still be seen and felt. However extensive the 
eruption of measles may become, it usually maintains its mottled, macular 
type, small areas of normal skin showing here and there throughout the 
eruption. The hyperemic character of this eruption is shown by the fact 
that it fades on pressure. This exanthem is one of the most characteristic 
of all eruptions, and when it occurs in a typical form can hardly be mis- 
taken for any other rash. No description, however, can present to the mind 
a very clear picture of this or any other eruption. When the physician has 
observed the typical measles exanthem and noted its characteristics as above 
outlined he will ever after recognize it. Variations in the eruption are not 
uncommon. It may, in rare instances, be so mild and evanescent as almost 
to escape attention, and again it may rarely occur as an hemorrhagic, pe- 
techial rash, covering the entire body. In this latter form, known as "black 
23 



336 MEASLES, KUBELLA, AND ERYTHEMA INFECTIOSUM 

measles/' hemorrhages from mucous membranes may occur and the dis- 
ease, especially in infants, not uncommonly has a fatal issue. Between the 
mild and the hemorrhagic types we may have every grade of severity, but 
the great majority of cases conform to the ordinary type as previously 
described. With the spread of the eruption, all of the catarrhal symptoms 
noted in the enanthem stage are greatly exaggerated. The conjunctival 
irritation, photophobia, coryza, bronchitis, cough, rapid breathing, fever, 
and nervous symptoms are all increased. Young children may have con- 
vulsions, older ones are nervous, irritable, sleepless, and sometimes deliri- 
ous. This aggravation in the symptom group continues until the eruption 
reaches its height, on or about the sixth or seventh day, when, rather sud- 
denly, there is marked improvement in the whole symptom-complex. The 

temperature begins to fall and may reach 
normal in one or two days. The eruption 
fades rapidly, the nervous symptoms dis- 
appear, and the child becomes comforta- 
ble, passing into a restful sleep ; the bron- 
chitis and its accompanying cough gradu- 
ally improve, and the exanthem stage has 
been transformed into the stage of con- 
valescence. 

Stage of Convalescence. — The stage 
of convalescence lasts for a week or ten 
days. During this time the bronchitis, 
conjunctivitis and other catarrhal symp- 
toms gradually disappear. The patient's 
appetite returns and he soon becomes im- 
patient of the restraint which his quaran- 
tine entails. Desquamation begins with' 
the fading of the eruption and continues 
for a week or ten days; it consists of 
small, fine, epithelial scales. 

The Blood. — During the preemptive 
stage there is a marked leukocytosis which 
falls to or below normal during the period of eruption. The polymor- 
phonuclears are increased during preemptive and eruptive stages; they 
fall below normal as the constitutional symptoms subside and return 
to normal during convalescence. The small lymphocytes are decreased 
during the height of the toxemia and increased as the symptoms begin to 
subside. The large mononuclears are increased late in the disease. The 
eosinophiles are decreased early in the attack and increased later. 

The Urine. — The urine during the febrile stage is scant, highly colored 

and may contain traces of albumin. Acute Bright's disease, however, is a 

very rare complication. The diazo-reaction occurs in nearly every case of 

measles (80 to 90 per cent.). Acetone and diacetic acid may be found. 

Complications. — Bronchopneumonia is the most common and the most 






ofS A onth 26 27 28 29 30 31 1 


ofS&ase ' 2 3 4 5 6 7 


107° 




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Fig. 55. — Measles Uncomplicated. 



MEASLES 



337 



dangerous of all complications. It occurs most frequently in hospital 
wards, where staphylococci, streptococci and pneumococci abound, and is 
seen most commonly in children under four years of age; it is at this 
time of life that bronchopneumonia is so dangerous. Henoch says that 
every fatal case of measles shows some pneumonia. Lobar pneumonia, due 
to a complicating pneumococcus infection, is not uncommon in older chil- 
dren, but the prognosis in this condition is, on the whole, favorable. Mem- 
branous laryngitis may be a complication of measles. In some instances 
this pseudo-membrane may be produced by cocci, but for clinical reasons 
it is safe to assume that it is always diphtheritic. While membranous 
laryngitis is rather an uncommon complication of measles, a severe spas- 
modic, catarrhal laryngitis, producing pronounced croupy symptoms, is not 



of month 26 27 28 29 30 31 1 2 3 4 5 6 7 8 9 10 II 12 13 14 


ofd.sease 1 2 3 4 5 6 7 8 9 10 II 12 13 14 IS 16 17 18 19 20 


107° 




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pulse E~!5!;iliSi55l§?:z2??S?! = IB?2l$Si2?tsss 


KtorlHA 1 IU1N m m m <n en en en mcn<G'G-o<T m <T . B -e*«rc»m<rTO«rm*r<r*3-tj'"tn*r t£>iOr^u3 •£> & o> a> 



Fig. 56. — Measles Complicated by Bronchopneumonia. 

at all uncommon. Tuberculosis is perhaps after all the most important 
complication of measles. In the chapter on Tuberculosis the remarkable 
prevalence of lymph-node tuberculosis is dwelt upon. The majority of 
children entering public hospitals have bronchial lymph-node tuberculosis, 
and this is one of the explanations for the frequency of bronchopneumonia 
among this class of patients. A large percentage of the bronchopneu- 
monias occurring as a complication of measles is tuberculous, hence the 
importance of recognizing the fact that measles, which irritates the bron- 
chial lymph nodes, is a disease especially liable to develop a latent into an 
active tuberculosis. General miliary and meningeal tuberculosis are not 
uncommon sequels of measles, and tuberculous pleurisy and empyema may 
occur. 



338 MEASLES, RUBELLA, AND ERYTHEMA INFECTIOSUM 

Measles may irritate and inflame the mucous membrane of the gas- 
trointestinal canal, in some instances causing a violent enterocolitis. This 
complication occurs especially in young children and may be serious, even 
fatal. Aphthous stomatitis and thrush may occur in young children, and 
their importance is increased by the fact that they must be differentiated 
from the enanthem of measles. Conjunctivitis, one of the catarrhal symp- 
toms of measles, may become aggravated and produce corneal ulcerations 
and inflammations of the lacrimal glands. Pemphigoid cutaneous erup- 
tions are rare and interesting complications, noted by many writers, but 
do not mean an unfavorable prognosis. Measles may also be associated 
with whooping-cough, scarlet fever and diphtheria. These mixed infec- 
tions usually occur in institutions. The combination of whooping-cough 
and measles frequently results in a fatal bronchopneumonia; diphtheria 



of iSonth ?0 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 


6 7 8 9 10 II 12 13 14 15 16 17 18 19 20 "2T2! 


of disease 1 2 3 4 5 6 7 8 9 !0 II 12 13 14 15 16 1 


18 19 20 21 22 23 24 lb 26 27 28 29 30 31 32 33 3< 


107" 








cc 


i 


i £:e?; ft?/;:::;:::::::::::::::: 




u 103 *-v y fe t -ft 




U 


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L A t\A 


| 99=1 M. P ,..^.,fl r .J.„L— A... _ "A a__-*J__Li 


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5 qq°::::: _ _ t s __z 


.__ h :__t_t dl 1:12:3:1:53: :::::_ 5 _ 




: / 


97 ; 


^ 



Fig. 57. — Measles Complicated by Bronchopneumonia. 



and measles commonly mean membranous croup; scarlet fever and measles 
may cause a septicopyemia. 

Prognosis. — The prognosis of uncomplicated measles in private practice 
is very good; nearly all such cases recover. In institutions it is very dif- 
ferent; the death rate here, on account of the prevalence of dangerous 
complications, may be very high. Age is a most important prognostic 
factor. Holt places the mortality of this disease under two years of age 
at 20 per cent., while the total mortality is only about 5 per cent. The 
prognosis is also influenced by the character of the epidemic. If the disease 
is prevailing in an unusually severe or malignant form the prognosis is 
much graver than it is in ordinary epidemics. The previous condition of 
the child, especially the presence of lymph-node tuberculosis, greatly in- 
creases the danger. The various complications previously noted add a 
gravity to the disease which belongs to the complication and not to the 
measles. 

Prophylaxis. — It is of the very greatest importance that young and 
tuberculous children should be protected from the contagion of measles. 



MEASLES 339 

To accomplish this a rigid quarantine should be instituted. If these two 
classes of children can be protected until they are older, they will be in a 
much better physical condition to withstand this disease. The laity, how- 
ever, cannot, as a rule, be brought in sympathy with rigid quarantine meas- 
ures in measles. They argue with some degree of truth that the child must 
have it some day and why not now, when it can be properly cared for. 
Whether or not the physician takes this view of the case with the normal 
healthy child over four years of age, there is no question as to his re- 
sponsibility in the matter of protecting the very young and the tuberculous, 
and in all instances it is his duty to insist upon a quarantine that will at 
least protect people outside the family. The young and tuberculous are 
better protected by sending them away from home when it is not possible 
to send the patient away. Following convalescence, the sick room and all 
of its belongings should be disinfected with formaldehyde and thoroughly 
ventilated and cleaned. This effectively destroys the contagion. 

Treatment. — Measles is a self-limited disease for which we have no 
specific medication. Treatment should therefore be directed to the relief 
of uncomfortable symptoms and the avoidance of complications. The pa- 
tient should be put to bed and kept there until convalescence is established. 
The bedroom should be well ventilated and kept at a temperature of about 
70° F. Sudden chilling of the surface of the body by great variations in 
the temperature of the room, or by draughts of cold air, or baths with 
cold water, are to be avoided. The patient should be sponged off with 
warm water once a day, and afterwards rubbed with lanolin or oil. If he 
complains of itching, carbolic acid may be added to the lanolin. The room 
may be slightly darkened, but light should not be excluded. The patient's 
eyes, especially if he suffers from photophobia, may be shaded. 

The dietetic treatment is important, especially in young children. 
All children under three years of age should be fed during the onset of the 
disease as though they had an enterocolitis. Barley water, broth, diluted 
skimmed milk, and peptonized milk are among the foods especially suitable 
to ward off gastrointestinal complications. In older children a light, simple 
diet, having milk for its basis, should be employed during the acute stage. 
A moderate amount of cool water may be taken, and where the throat 
symptoms are especially irritable small bits of ice in the mouth are per- 
missible. The prejudice of the laity against cold drinks and cold baths 
may, to a certain extent, be respected without inflicting great punishment 
on the patient; but the hot bedroom, hot drinks and heavy bed clothing, 
for the purpose of "bringing out" the eruption, are superstitions which may 
be resisted, greatly to the comfort of the patient. 

Symptomatic Treatment. — The cough and bronchial irritation usually 
require treatment. In younger children the bromid of potash or soda, 
combined with small doses of belladonna, put up in essence or elixir of 
pepsin, usually allays the cough; if this does not suffice, small doses of 
chloral may be added to this mixture. In older children it may be ad- 
visable to control the irritable cough with small doses of codein or pare- 



340 MEASLES, RUBELLA, AND ERYTHEMA INFECTIOSUM 

goric, but it should be remembered that these opiates are in no sense cura- 
tive and their effect should therefore be carefully studied; if they benefit 
the patient more than they do him harm, they may be continued. These 
drugs produce constipation and interfere to a certain extent with the ap- 
petite and digestion. Syrups and expectorants should never be used. I do 
not believe any good whatever can result from the syrup of ipecac, syrup 
of squills and ammonia preparations commonly used, and I know that they 
may do much harm by disturbing the appetite and digestion. They should 
at least never be given to young children. The fever and nervous symp- 
toms may be controlled by sponging with lukewarm water, and by the giv- 
ing of antipyrin, aspirin and phenacetin in doses suited to the age of the 
child. I do not believe any harm whatever results from the use of anti- 
pyrin associated with tincture of strophanthus and combined in a suitable 
elixir, and I do believe that this prescription, when given in proper doses 
to suit the age of the child, will very materially relieve the distressing 
symptoms and thereby add to the comfort of the patient, during both the 
enanthem and exanthem stage of this disease. The following prescription 
may be used : 

1$ Antipyrin 3 ss 

Tinct. strophanthus 3 ss 

Tinet. belladonnge 3 ss 

Elixir lactated pepsin ad § iii 

Teaspoonful every four hours for a child four years of age. 

If lung complications develop, guaiacol inunctions and carbonate of 
guaiacol internally should become a part of the routine treatment. With 
the onset of septic symptoms and especially pneumonia, the guaiacol oint- 
ment is changed for unguentum Crede and a number of doses of antistrep- 
tococcic serum given, as outlined in the treatment for scarlet fever. In 
older children inhalations of creosote and oil of eucalyptus may be used as 
a bronchial antiseptic, and to relieve the symptoms resulting from respira- 
tory irritation. No medicines are necessary to bring out the eruption, 
but, in cases where it has failed to come out properly and a broncho- 
pneumonia is threatening or has already begun, warm mustard baths may 
be of value in increasing the peripheral circulation and relieving the pul- 
monary congestion. These cases may also be benefited by applications of 
warm camphorated oil applied under an oil silk jacket, as outlined in the 
Treatment of Bronchopneumonia. Cathartics are to be used cautiously 
in the treatment of measles. Enemata commonly suffice to keep the bow- 
els open; when necessary, however, a mild cascara laxative may be used. 
If enteritis threatens castor oil should be given and the patient placed on 
the diet outlined under Enterocolitis. Pneumonia, tuberculosis, mem- 
branous laryngitis and other complications are to be treated as elsewhere 
noted. In membranous laryngitis it is always safest to administer diph- 
theria antitoxin, even though there may be a possibility that the pseudo- 
membrane is produced by cocci. The eyes should be properly protected 



EUBELLA 341 

during convalescence, and their use for reading and other close work should 
be prohibited until all traces of conjunctivitis have disappeared. 



RUBELLA 

(Rotheluj German Measles) 

Eubella is an acute infectious disease in no way related to ordinary 
measles. It is characterized by slight fever, enlargement of the post- 
cervical lymph nodes and by a rash resembling in some particulars both 
that of measles and scarlet fever. 

• Etiology. — Breast-fed babies under six months of age are practically 
immune. During the latter half of the first year of life the susceptibility 
to this disease gradually increases. From that time on nearly every in- 
dividual is susceptible. Age does not confer immunity. Adults and chil- 
dren alike nearly always contract the disease when they come in close con- 
tact with the infection. Epidemics are much more common during the 
winter months. 

The specific microorganism of rubella is unknown, and like the con- 
tagious principle of measles it is short-lived after it leaves its host. The 
contagion does not, for any length of time, cling to and contaminate the 
clothes, bedding and other belongings of the patient. It is spread by the 
well coming in contact with the sick; rather close contact is necessary. 
There is little or no danger of a third party carrying the contagion from 
the sick to the well. The infection, however, may be carried short dis- 
tances through the air and by fomites. There is great variability in the 
contagiousness of this disease in different epidemics. The period of con- 
tagion begins a day or two before the eruption appears and lasts until it 
disappears. 

Immunity. — One attack confers immunity; second attacks are very 
infrequent. An attack of this disease does not afford protection from 
measles or scarlet fever, nor do these diseases protect the patient from 
rubella. Eubella, measles and scarlet fever may follow each other in 
rapid succession as house epidemics in the same family. 

Incubation. — The period of incubation varies from ten to twenty days. 
Griffith reports a case where it was one day. It would appear, therefore, 
that the incubation period is either very variable, or that more accurate 
observations are necessary to establish its limits. 

Symptomatology. — The onset is commonly mild. The rash may be 
the first symptom noted. It may be accompanied or preceded by a slight 
elevation of temperature, a feeling of general malaise, headache and back- 
ache. There may be mild catarrhal symptoms, such as slight pharyngitis, 
coryza and infection of the conjunctiva. A slight cough and gastric 
disturbance may be present. The fever does not run high. In some in- 
stances it may scarcely be above normal. In severe cases, especially in 
young children, it may reach 103 °F. Its maximum is commonly attained 



342 MEASLES, BUBELLA, AND ERYTHEMA INFECTIOSUM 

within the first thirty-six or forty-eight hours, and it then subsides. There 
is nothing at all characteristic in the fever, pulse, or respirations. 

The enanthem of this disease is always present and is a valuable aid 
in differentiating it from other acute infections. Forchheimer says of this 
enanthem: "It consists of a macular, distinctly rose-red eruption, upon 
the velum of the palate and uvula extending to, but not on, the hard 
palate. The spots are arranged irregularly, not crescentically, of the size 
of large pin-heads, very little elevated above the mucous membrane, and 
do not seem to produce any reaction upon it." The enanthem appears 
just before or simultaneously with the exanthem or skin eruption, and 
lasts one or two days. The whole mucous membrane of the throat, espe- 
cially the pharynx, is red and congested. 

The exanthem, or skin rash, is of special value in diagnosis when it 
is associated with Forchheimer's enanthem. The skin rash in and of itself 
is very puzzling from a diagnostic standpoint, because of its variations. It 
commonly appears as small, pale rose-red spots somewhat smaller than 
the measles macule. This rash, however, resembles to a certain extent the 
measles eruption, but is lighter in color. These macules may coalesce as 
in measles, forming patches of rose-red colored skin. In other instances 
the rash may occur as fine, red points producing more or less uniform 
redness of the skin. This type of the eruption, therefore, more closely re- 
sembles the exanthem of scarlet fever. It has not, however, the scarlet 
hue and can usually be differentiated from scarlet fever by the rose tint 
and less punctate form of the rash. Both forms disappear on pressure. 
In some cases the two eruptions occur in the same patient; on one por- 
tion of the body the macular measles-like eruption predominates, and on 
another the uniform rose tint, somewhat resembling scarlet fever, may be 
seen. The exanthem begins on the face and spreads downward, involving 
the neck and body and lastly the arms and legs. A point of diagnostic 
importance is that the eruption, unlike that of scarlet fever, appears on 
the lips close around the mouth. Another point of great diagnostic 
importance is that the rash, unlike those of measles and scarlet fever, 
appears on the first day of the disease, reaches its maximum by the 
second day, and then begins to fade. It may entirely disappear in 
one or two days, or traces of it may linger for a week or ten days. 
The severity of the disease is not measured by the length of time the 
rash continues. It may disappear and again return; this, however, is very 
uncommon. 

The irritation of lymphatic tissues is very characteristic of this 
disease. The spleen in almost every instance is slightly enlarged, and can 
be palpated. Enlargement of the posterior cervical lymph nodes is a 
constant and distinctive feature, since they are not so uniformly enlarged 
in any of the other acute infections. The nodes in the neck most com- 
monly enlarged are the post-cervical, the suboccipital and the post-auricu- 
lar. The anterior cervical nodes, however, may also be enlarged and the 
superficial lymph nodes throughout the body can commonly be felt. 



ERYTHEMA INFECTIOSUM 343 

The blood shows a polynuclear leukocytosis during incubation and 
leukopenia during the stage of eruption. 

The Urine. — The diazo-reaction, which is so constantly present in 
measles, is absent in this disease. 

Complications. — The lighting up of a latent tuberculosis is the most 
common complication of rubella. Other complications are rare. In the 
more severe cases gastrointestinal and respiratory diseases may occur. 

Prognosis. — This is good. Fatalities have been reported in epidemics 
of extreme severity. 

Treatment. — The patient should be isolated until a positive diagnosis 
has been made. It is a matter of serious import to mistake a mild scar- 
latina for rubella. The diagnosis once established, the disease is so simple 
as not to require a rigid quarantine. Patients, however, should be confined 
to their homes, so as to prevent spreading the disease. 

The average patient requires no medical treatment. In the more se- 
vere cases a mild laxative should be given, and the patient confined to 
bed for one or two days. Small doses of antipyrin and phenacetin may 
be given to relieve the fever and nervous symptoms. 



ERYTHEMA INFECTIOSUM 

Erythema infectiosum is an acute infectious disease first described by 
Escherich. It is characterized by a rose-red rash with slight or no con- 
stitutional symptoms. 

Etiology. — This disease is believed to be rare in America, although in 
recent years small epidemics have been observed in our larger cities. 
Infants under one year of age are immune. Older children are commonly 
affected, and adults are susceptible. It usually occurs in epidemics. The 
specific organism is unknown. It is spread, however, by contagion, 
rather close contact being necessary, and it is in no way related to rubella, 
scarlet fever or measles. 

Symptomatology. — After an incubation period of ten or twelve days an 
erythematous eruption may appear on the face. This rather brilliant red 
rash spreads over the cheeks onto the body. Parts of the skin, however, 
are commonly normal in color, giving the eruption a blotchy appearance. 
It is a typical erythema, having much the appearance of erysipelas, except 
that the skin is not inflamed as in that disease. The exanthem lasts for 
about one week, gradually fading, and is not followed by desquamation. 
The patient may suffer from slight headache and sore throat. The tem- 
perature rarely rises above 100° F., so that this condition is practically 
an afebrile disease. The lymphatic tissues are not involved as they are 
in rubella. 

Prognosis. — This is always good, and no treatment is required. 

The following table from Ruhrah will assist in the differentiation of 
the acute exanthemata : 



344: MEASLES, RUBELLA, AND ERYTHEMA INFECTIOSUM 



Differential Diagnosis of Rubella, Scarlet Fever, Measles and Erythema 

Infectiosum 





Rubella 


Measles 


Scarlet 
Fever 


Erythema 
Infectiosum 


Contagion 


Apparently varies in 


Highly contagious. 


Marked. 


Feeble. 




epidemics. 


By direct contact. 


By direct contact. 


Usually by direct 




Direct contact. 


By fomites. 


By fomites. 


contact. 




Possibly from fomi- 


Through the air. 








tes, not through the 








Incubation. 


Variable average 1 
to 3 weeks. 


Average 9 to 14 days. 


Average 1 to 6 days. 


Average 6 to 14 

days. 


Prodromes. 


Slight and of short 


3 to 4 days. 


Short or wanting — 


Very slight and of 




duration. 


Drowsiness and ca- 


onset usually sud- 


short duration. 




Occasionally a day 


tarrhal symptoms. 


den. 






or two of malaise. 








Koplik spots. 


None. 


Present in 90 or 95 
per cent, of cases. 


None. 


None 


Vomiting. 


Rare. 


Occasional. 


Common. 


Uncommon. 


Fever. 


Slight — average 1 to 


Marked high curve 


High fever lasting 


Little or none. 




2 days, sometimes 


lasting about a 


about a week, aver- 






for 4 days, seldom 


week, average from 


age 104° to 105°. 






more than 101° to 


102° to 104°. 








102°. 








Catarrhal symptoms 


Slight. 


Marked. 


Absent. 


None. 


Tongue. 


Slight coat, nothing 


Tongue coated, that 


Strawberry, later 


Sometimes slightly 




characteristic. 


of any fever. 


mulberry tongue. 


coated. 


Throat. 


Small, punctiform, 


Moderate pharyn- 
gitis and redness of 


Usually a severe 


Sometimes very 




red spots over 


angina. 


slight sore throat 




uvula and palate. 
Pharynx slightly 


mucous membranes 




at onset. 












reddened. 








Diarrhea. 




Frequent. 






Lymph nodes. 


General enlargement 


Postcervical, post- 


Depends on extent 


Not enlarged. 




especially of post- 


auricular, and sub- 


of throat involve- 






cervical nodes. 


maxillary nodes en- 
larged. 


ment, glands at 
angle of the jaw 
involved. 




Pulse. 


Varies with fever. 


Varies with fever. 


Very rapid 


Normal. 


Albuminuria. 


Rare and slight. 


Rare. 


Common. 


None. 


Eruption. 


Begins on face, 


Begins on face, 


Begins on neck and 


First on face as 




spreads to neck and 


spreads gradually 


chest, spreads slow- 


symmetrical, rose- 




breast,then to arms, 


over entire body, 


ly over entire body 


red blush, for the 




legs and feet. Is fad- 


covering it by the 


— maximum about 


most part sharply 




ing from older parts 


second or third day. 


the fourth day. 


defined and re- 




while spreading to 


Consists of small 


Does not affect lips. 


sembling erysipe- 




new. Two forms 


papules arranged in 


Consists of small, 


las. It is hot to 




— common form, 


crescentic groups ; 


punctate spots or a 


the touch but not 




morbilliform, small, 


these are confluent 


diffuse blush; dis- 


sensitive and it 




slightly elevated 


in places. Lasts 


appears on pres- 


does not itch. The 




papules, discrete, 


4 to 5 days. Is 


sure; lasts about a 


second day it 




sometimes con- 


deep red, often pur- 


week. Intense red 


spreads to the 




fluent; more rarely 


plish. 


color. 


body and extremi- 




scarlatiniform, lasts 






ties, small discrete 




2 to 4 days or less, 






crescentic patches 




color rose-red but 






over the body and 




this varies. 






sparingly on the 
inner and flexor 
surfaces of limbs. 
Marked map-like 
eruption on outer 
and extensor sur- 
faces. Begins to 
fade on face in 4 
or 5 days. Lasts 
altogether 6 to 10 
days. 


Desquamation. 


Slight and branny. 


Branny. 


Marked in flakes and 

large pieces. 
Slow, complications 


None. 


Convalescence. 


Rapid, no complica- 


Slow, frequent com- 


Rapid, no^complica- 




tions. 


plications, as pneu- 
monia. Later other 
infectious diseases, 
as tuberculosis. 


frequent, as nephri- 
tis, otitis media, 
etc. 


tions. 



VABIOLA 345 



CHAPTEE XLI 

VAKIOLA, VACCINIA AND VARICELLA 

VARIOLA 

Variola, or smallpox, is an acute infectious and highly contagious 
disease characterized by more or less severe constitutional symptoms and 
by a specific eruption passing through the stages of papule, vesicle, pus- 
tule, scab and scar. The disease has no peculiar manifestations in child- 
hood, running much the same course at all ages. Before the days of vac- 
cination the disease was almost confined to childhood, 90 per cent, of the 
cases occurring in children under ten years of age. The immunity of 
adults during that period was due to the fact that a vast percentage of 
the adult population was immune from having had the disease. At the 
present time, however, by reason of the fact that nearly all children are 
vaccinated, the disease is rarely seen in childhood. It is now, therefore, in 
civilized communities, a comparatively rare disease confined almost ex- 
clusively to adults, among whom the immunity which resulted from early 
vaccinations has wholly or partially expired. The disease is so infrequent 
at the present time that it is rarely seen in private practice. Many physi- 
cians with a long and active medical career have never come in contact 
with it. 

Etiology. — The specific microorganism of smallpox is now believed to 
be the '"Cytoryctes Variola 3 / 7 a parasitic protozoa, first clearly described by 
Guanieri in 1892, and subsequently shown to be etiologically related to 
this disease by Councilman and his associates. 

Contagiousness. — It is the most highly contagious of all infectious 
diseases, being spread directly by contact of the sick with the well, and 
indirectly by the contagion being carried by a third party, and by clothing, 
bedding, and other belongings of the sick room. The contagion is given 
off from the lungs, and by the discharges from the vesicles and pustules 
of the skin eruption. The dry crusts may carry and transmit the disease 
long distances. It is believed that it may be transmitted through the air 
for distances sufficient to make house to house contamination possible. 
The contagion lasts from the beginning to the end of the disease, but is 
very slight until the skin eruption appears. Race and sex offer no bar- 
riers to its dissemination. The cold winter months furnish conditions 
favorable to its spread. Age does not confer immunity, but children are 
slightly more susceptible than adults. 

Incubation. — Smallpox has a very definite period of incubation: this 
is usually ten to twelve days, and it is believed that its limits are from 
five to twenty days. 

Symptomatology. — The Stage of Ixvasiox. — The onset is marked by 
very pronounced symptoms. Headache, backache, convulsions, gastric dis- 



346 VARIOLA, VACCINIA, AND VARICELLA 

turbance and profound depression are present in typical cases. In older 
children and adults a chill takes the place of the convulsion. There may 
be great variation in the severity of this initial symptom group. Occasion- 
ally severe cases have a mild onset, but, as a rule, the initial toxemia is 
pronounced; this is especially so in unvaccinated children in whom the 
nervous system is profoundly affected. Not infrequently convulsions, stu- 
por, coma, delirium and profound depression occur. The stage of inva- 
sion lasts for about three days, during which time severe backache in the 
lumbar region is a rather characteristic symptom, and the headache may 
continue to be so severe that therapeutic measures are required for its 
relief. The initial vomiting may not be repeated, but loss of appetite and 
gastric discomfort are present. The fever rises rapidly with the initial 
chill; it may reach 104° or 105 °F. within the first twenty-four or thirty- 
six hours. It usually reaches its highest point on the second or third day, 
and then, in the less severe cases, falls rapidly to normal, and even in 
severe cases there is a sharp fall in temperature. After this fall there 
may be only a slight elevation of temperature during the next few days, 
when there is a secondary rise coincident with the formation of pustules. 
This septic or secondary fever continues for a number of days, during 
the pustular stage, and then falls to normal as convalescence approaches. 
The height and duration of the secondary rise in temperature will depend 
upon the severity of the infection and the character of the eruption. Dur- 
ing the stage of invasion cutaneous eruptions may occur in a small per- 
centage of cases. Both erythematous and petechial rashes are seen; the lat- 
ter, which occur about the second day, when associated with the symptoms 
above noted, are of diagnostic importance. 

The enanthem is one of the most valuable of diagnostic symptoms, 
as it commonly occurs from twelve to twenty-four hours before the skin 
eruption. It consists of small red papules which can be distinctly seen 
and felt on the hard and soft palate, and may occur on any portion of 
the mucous membrane of the mouth. These papules become vesicles, and, 
if not ruptured, pustules; the rupture, however, usually occurs during 
the vesicular stage. As an examining physician to a large general hos- 
pital many years ago, I had the opportunity of testing the value of the 
enanthem in making an early diagnosis of these cases. During the epi- 
demic of smallpox then prevailing every patient applying for admission 
to the general hospital was carefully examined for the smallpox enanthem 
and in many cases the diagnosis was made upon this sign and the patient 
sent to the smallpox hospital, to break out the next day with a typical 
skin eruption. The importance of making the diagnosis at this early period 
is greater because the time of great contagiousness begins with the exan- 
them stage. Prior to this the disease is but feebly contagious. 

Stage of Eruption. — About the third day the characteristic skin- 
eruption commences to make its appearance, and the pain in the back, 
headache, gastric disturbance and fever quickly subside. The eruption 
first shows itself as small red papules, which can be felt as well as seen; 



VARIOLA 347 

as they increase in size they give to the skin a peculiar shotty feel. On 
the third day the papule becomes slowly transformed into a vesicle filled 
with slightly grayish fluid; as the vesicle increases in size it becomes dis- 
tinctly umbilicated and is surrounded by a small hyperemic zone. About 
the eighth or the ninth day the vesicle is converted into a pustule, the 
contained fluid having a yellow color. During this time as the pustule 
matures the surrounding skin becomes more indurated and inflamed, so 
that if the pustules are located near together, the whole surface becomes 
inflamed and indurated. The pustule maintains its umbilicated form for 
a number of days and then slowly begins to dry, forming a brown scab. 
This change commences about the twelfth day, and with it the surround- 
ing skin becomes less inflamed; as the inflammation subsides the crusts 
become dryer and begin to drop off during the third week, leaving a red 
scar. General desquamation then begins and is usually completed about 
the end of the sixth week; in milder cases earlier, in more severe cases 
later. The smallpox eruption first makes its appearance on the face, then 
spreads to the trunk and later to the extremities. It is especially profuse 
around the neck and back, and not so marked below the knees and on the 
abdomen. As previously noted, there is a secondary rise of fever during 
the pustular stage, and as the eruption reaches its height, about the ninth 
or tenth day, the skin may become so swollen as to produce great pain. 
In severe forms of the disease, where the skin is very intensely inflamed, 
the pain is very acute; the location of individual pocks, as for example 
under the nail, in the auditory canal, and in the larynx, and in the eye, 
may greatly increase the suffering, and in the latter location may result in 
loss of sight. 

The Urine. — Welsh and Schamberg found albuminuria in 50 per 
cent, of cases which recovered, and in 84% per cent, of the fatal cases. 
Acute Bright's disease, however, is a rather rare complication. 

Blood. — There is, as a rule, a marked leukocytosis, especially during 
the vesicular stage. The lymphocytes are increased and the polymor- 
phonuclears decreased. The red blood cells are greatly diminished in the 
later stages of this disease. 

Clinical Forms. — Variola may present itself in many forms. The mild 
cases have been termed varioloid. These commonly occur in vaccinated 
individuals in whom the immunity derived from the vaccination has par- 
tially run out. In these cases the constitutional symptoms are mild and the 
eruption very slight ; only a few pocks may occur. From this mild type we 
have every grade of severity to the confluent form, in which the pustules are 
so close together that they become confluent, and the associated dermatitis is 
therefore very much aggravated. In these cases the constitutional symptoms 
are not only severe, but the pustular stage of the disease presents a very 
revolting picture ; the patient's face and eyes being so swollen that he can- 
not be recognized by his best friend. Hemorrhagic smallpox is a very grave 
form, in which the pocks become hemorrhagic and hemorrhages occur from 
mucous membranes. The constitutional symptoms are profound and death 



348 VARIOLA, VACCINIA, AND VARICELLA 

usually results. Purpuric smallpox is a fatal form in which petechial 
hemorrhages appear as early as the third day, taking the place of the ordi- 
nary eruption. Hemorrhages occur from mucous membranes and from 
the kidney and the patient dies, as a rule, before the characteristic erup- 
tion is developed. 

Diagnosis. — Before the skin eruption appears, the diagnosis of small- 
pox may be made by the constitutional symptoms, the petechial rash, and 
the typical enanthem on the palate. After the skin eruption appears the 
only disease with which smallpox is likely to be confused is chickenpox, 
and the differential diagnosis of these two conditions is given in the chap- 
ter on that disease. 

Prophylaxis. — Vaccination is the all-important measure in the prophy- 
laxis of smallpox. The disease may be prevented in this way. This sub- 
ject is discussed under Vaccination. The only other measure of any 
importance is the absolute and complete isolation of the patient, and this 
can only be done satisfactorily by removing the patient to a smallpox 
hospital. If he is treated at home the other members of the family should 
leave the house, and he should be given into the hands of the doctor and 
trained nurses. Under these conditions the most rigid quarantine pos- 
sible should be established, even more rigid than that described under 
Scarlet Fever. 

Treatment. — During the stage of invasion the patient is to be made as 
comfortable as possible by symptomatic treatment. For the fever, frequent 
spongings of the body with cool water should be resorted to if it adds to 
the comfort of the patient. An ice-bag to the head will modify the head- 
ache, the nervous symjrioms, and help to reduce the temperature. Bromid 
of potash, chloral and, if necessary, sulphate of codein or morphin, in doses 
suited to the age of the child, may be used to relieve the intense suffering 
of this stage. Chloral and bromid of potash are especially valuable in 
young children for the control of the convulsions and other nervous symp- 
toms, and if the stomach be so irritable that these drugs cannot be given by 
the mouth, then the chloral alone should be given by the rectum. The 
diet during the acute stage should consist of milk, cereals, bread and fruit 
juices, the object being to furnish nutrition without overtaxing the diges- 
tive organs or the kidneys. 

With the secondary rise in temperature which occurs during the pus- 
tular stage of the eruption, active symptomatic treatment is again de- 
manded to relieve the distress produced by the swelling and inflammation 
of the skin. The itching during this stage may be very great and the pa- 
tient must be prevented from scratching. The tearing of the pocks on the 
face should be especially guarded against to prevent scarring. Cold ap- 
plications offer the greatest relief; these may be made by wringing cloths 
out of ice-cold water and applying them as a mask to the face or to other 
portions of the body where the suffering is intense. Carbolic acid may 
be added to the water, as this helps somewhat to relieve the itching. In 
severe cases the eye demands careful attention, and as the conjunctivitis 



VACCINIA • 349 

becomes marked it is necessary to separate the lids and wash out the ac- 
cumulated discharges with a weak boric acid solution. Cloths wrung out 
of ice-water should be applied to the lids. Pharyngitis should be treated 
by weak alkaline antiseptics. In rare cases the eruption extends to the 
larynx, threatening suffocation; this condition may demand tracheotomy. 
As smallpox in the unvaccinated is a very dangerous disease and one in 
which rather sudden collapse is not uncommon, active stimulation may be 
demanded at any time. For this purpose alcohol in the form of whiskey 
or brandy should be freely administered in combination with tincture of 
strophanthus or tincture of digitalis. The red-light treatment of small- 
pox is believed to exercise a favorable influence on the skin lesions. This 
can be used only in a specially prepared room where all the light is fil- 
tered through red glass. 

VACCINIA 

Cowpox is believed to be modified smallpox, as it occurs in the cow; 
it manifests itself in a vesiculo-pustular eruption on the udder and teats. 
Vaccination with the virus of the cowpox vesicle communicates this disease 
to man, producing vaccinia and protecting him from the contagion of 
smallpox for a variable length of time. 

History.- — Before the time of Jenner it was known to dairy workers 
that an attack of cowpox conferred immunity from smallpox. In fact 
Jenner's attention was called to this subject by coming in contact with 
dairy people. After a careful investigation he made his first vaccination 
on May 14, 1796. This was done with virus taken from a milkmaid suf- 
fering from cowpox; the subject was a boy named James Phipps; subse- 
quently with the same virus he vaccinated his own son, and a number of 
other children. Later he inoculated some of these children with the virus 
of smallpox and otherwise exposed them to the contagion of this disease, 
but none of them contracted it. Jenner continued his investigations over 
a period of two years, and in 1798 published his observations in which he 
stated that patients who had had cowpox were ever after protected from 
smallpox, and that smallpox could therefore be prevented by inoculating 
the patient with cowpox. Thus originated perhaps the greatest of all med- 
ical discoveries, vaccination; a discovery which has saved more lives than 
any other, and which has almost obliterated smallpox, the most terrible 
pest of the seventeenth and eighteenth centuries. 

It is difficult for us at the present time to realize that the discovery 
of vaccination by Edward Jenner was and still remains the greatest of 
all triumphs of preventive medicine. Crandall, who has most carefully 
studied the vast literature of this subject, says: "A hundred years ago 
smallpox was justly regarded as the Attila of diseases, the very scourge 
of God, overrunning countries and destroying populations. When Jenner 
performed his first vaccination it was causing one-tenth of all the deaths 
of the human race. Bernouilli, the mathematician, estimated that more 



350 VABIOLA, VACCINIA, AND VARICELLA 

than 60.000,000 of the inhabitants of Europe died of smallpox during the 
eighteenth century. Others place the number even higher. Specific proof 
of its fatality is shown by Cowan's vital statistics of Glasgow. In that 
city between 1783 and 1792, 36 per cent, of all deaths under ten years 
of age were due to smallpox. One-third of all the deaths in Europe under 
ten years were due to the same cause. When smallpox was introduced into 
Mexico by the Spaniards in 1520, 3,500,000 died within a few years. In 
1737 in Iceland, 18,000 in a population of 50,000 died in a single year. 
It is believed that 6,000,000 North American Indians fell victims of its 
ravages/' In contrast with this let me quote the opening sentence of a 
recent encyclopedic article on smallpox by Ch. Baumler, of Freiberg: 
"There has been no opportunity of observing variola in any form in this 
clinic for nine years; still it is necessary for every well-informed physician 
to have a knowledge of this important disease. As a result of strict vac- 
cination and revaccination in Germany, the disease has been prevented 
from appearing, so that many physicians have never had an opportunity 
of seeing smallpox." The results which have been attained by Germany 
could be obtained in other countries if compulsory vaccination were 
adopted. In the United States smallpox is kept alive by the fact that 
there still exists an ignorant negro and uneducated foreign population and 
a few fanatics who "do not believe in vaccination." 

The Vaccine Virus. — In the early experiments vaccinations were made 
with the lymph taken directly from the cowpox vesicle. Later humanized 
virus came into very general use, the subject being vaccinated either 
with the fresh lymph from a human vaccine vesicle or with the dried 
lymph in the form of scabs or crusts which came from the matured vac- 
cine vesicle. As time went on public opinion was much opposed to the 
use of humanized virus, because of the exaggerated views then prevalent 
of the danger of transmitting syphilis, tuberculosis and possibly other 
diseases. At the present time humanized virus is rarely used, bovine 
virus having taken its place. This vaccine virus is now prepared from 
the serum of the cowpox vesicle, and is put on the market in the form of 
a glycerinated bovine virus in hermetically sealed tubes, or on ivory points 
which are themselves protected from contamination by being put up in 
glass tubes or other coverings; the object being to present to the public 
a pure, sterile bovine virus which can be used without fear of infecting 
the patient with pathogenic organisms. 

Technique of Vaccination. — Vaccination is to be performed under 
strictly aseptic conditions. The skin is to be carefully cleansed with soap 
and water and then with alcohol. The operation may be made with an ordi- 
nary sewing needle, or with the sterile ivory vaccine points above described. 
If the needle is used it should be sterilized by heating, and with its point 
the skin is to be carefully scratched four or five times, both in a longi- 
tudinal and transverse diameter, producing a raw surface about one-sixth 
of an inch square. The scarification should be deep enough to remove 
the superficial epithelium, leaving a red, raw, but not bleeding, surface. 



VACCINIA 351 

Into this raw surface the vaccine virus is rubbed with the ivory vaccine 
point, or some other sterile instrument. The wound should then be allowed 
to dry before the clothing comes in contact with it; this commonly re- 
quires fifteen or twenty minutes. Following this operation the vaccine 
wound is to be carefully protected from traumatic injury and infection. 
The point on the skin usually selected for vaccination is the upper and 
outer surface of the left arm at or near the insertion of the deltoid. An- 
other point of selection is the outer surface of the left leg, six or eight 
inches above or below the knee. Of these two locations the arm is by 
far the best. The leg, however, may be selected in young infants under 
one year of age, since at this time of life it is almost as easy to properly 
care for the vaccine wound on the leg as it is upon the arm. In children 
old enough to be upon their feet there is more or less danger that the 
vaccination wound on the leg may be injured and contaminated; for this 
reason first vaccinations in older children should always be made on the 
arm. If not, the parents should be made to assume the responsibility of 
keeping the child off its feet during the period of marked inflammation 
in and around the vaccine vesicle. For esthetic reasons the physician is 
very frequently requested to vaccinate girls upon the leg, as the scar upon 
the arm is unsightly. Vaccination should, if possible, be performed during 
the first year of life, but it is advisable to wait until after the child is 
three months of age, or until its nutritional problems are solved; it is 
then ready for vaccination, and the earlier the operation is made the 
milder will be the course of the vaccinia and the less trouble will there 
be in the care of the wound. If, however, the infant be tuberculous or 
come from a tuberculous family, or if it be malnourished from lack of 
proper food or other causes, vaccination may be postponed until these 
nutritional faults are corrected. In the meantime, however, should small- 
pox appear in the community, the child should be vaccinated without fur- 
ther delay. 

Incubation Period. — The incubation period of vaccinia, is from three 
to five days, that of smallpox eight to twenty days; the average incuba- 
tion period of vaccinia is four days, that of smallpox twelve days. These 
are most important facts, since they explain why a patient who has been 
exposed to smallpox may even then be protected by prompt vaccination. 
If the vaccination be made within the first day or two after exposure to 
the smallpox contagion, the patient may escape smallpox, as the vaccinia 
reaches its height before smallpox has had time to develop. If the vac- 
cination be made four or five days after exposure to the smallpox con- 
tagion, the vaccinia may still precede the smallpox in its development and 
cause it to run a very mild course. 

Clinical Manifestations.- — Directly following vaccination the wound 
heals and on the fourth or fifth day thereafter a faint red spot makes its 
appearance, which soon manifests itself as a papule with a red base. On 
the sixth or seventh day this papule becomes a vesicle of grayish color with 
a slight zone of redness and contains a clear sterile lymph. On the eighth 
24 



352 VARIOLA, VACCINIA, AND VAEICELLA 

clay the vesicle becomes contaminated with bacteria and the lymph be- 
comes clouded with pus corpuscles, so that by the tenth day a pustule has 
taken the place of the vesicle. In the meantime as the pock develops from 
the vesicle into the pustule it becomes umbilicated, a slight central de- 
pression showing on the eighth or ninth day. During this time the zone 
of redness which surrounded the vesicle is much increased in size and en- 
circles the pustule from half an inch to an inch or more in every direc- 
tion; this zone is more or less thickened and indurated and, near the pus- 
tule, slightly tender to the touch. From the ninth to the eleventh day the 
disease is at its height, and during this period adjacent lymph nodes are 
swollen and tender. When the arm is the site of the vaccination the 
axillary lymph nodes are especially involved, and may appear as hard, 
tender tumors the size of a hickory nut. After the eleventh day the in- 
flammatory process subsides, the umbilicated pustule begins to dry up 
and form a scab. The axillary lymph nodes diminish in size, the sur- 
rounding zone of redness and induration gradually diminishes, and all 
the acute symptoms disappear. The scab or crust does not usually fall 
off until the end of the third week, and may remain a week longer. Dur- 
ing this period great care should be exercised to have it remain as long 
as possible, to be finally cast off by necrotic processes which have under- 
mined it. With the falling off of the scab a depressed, red surface is left, 
which later marks the site of the permanent scar, which usually has a 
pitted appearance. 

With the onset of other acute symptoms fever usually appears on the 
eighth or ninth day. In infants under one year of age the fever is very 
slight, and even in older children it does not commonly rise above 102° 
or 103°F. ; it may, however, reach 104°F. Soon thereafter the tempera- 
ture begins to fall and may reach normal within two or three days. The 
febrile reaction in vaccinia varies greatly. It may be very slight and 
evanescent, and it may be well marked and last for four or five days 
without indicating septic contamination of the wound or other complica- 
tions. The typical lesion or pock of vaccinia in first vaccinations runs 
the same course as the lesion of smallpox. It is first a papule, then a 
vesicle, pustule, scab and scar. These stages, however, are milder and 
shorter in vaccinia than they are in smallpox, but they are characteristic 
of vaccinia, and a vaccine sore that does not present this sequence is ab- 
normal, and may not afford protection against smallpox. The severity of 
the course of vaccinia does not increase its power of protection. The mild 
course which this disease runs in infancy confers immunity for as long 
a period as the more severe vaccinia of the older child. On the other hand, 
it should also be noted that vaccinia marked by severe local and constitu- 
tional symptoms is not to be considered abnormal, provided the disease 
runs the typical course above outlined. It simply means that some in- 
dividuals are more susceptible to vaccinia, as they are to other contagious 
diseases. 

Secondary Rashes.— In some instances a dark red swelling occurs at 



VACCINIA 353 

the point of vaccination instead of the typical sore. This has been de- 
scribed as the "raspberry excrescence." It is firm, considerably elevated 
above the surface of the skin, but is not inflamed or tender, and has no 
discharge. This condition is brought about by some abnormality in the 
virus used and offers no protection against smallpox. It commonly per- 
sists for weeks and may last for months before it finally disappears. As- 
sociated with normal vaccination we occasionally have a general vaccinia 
eruption, in which the pustules may be scattered in large numbers over 
the surface of the body, resembling chickenpox. These pocks run through 
the typical stages of the local sore produced by vaccination, but they are 
much smaller and run their course in a shorter time. Erythematous rashes 
resembling German measles, mottled rose-colored patches resembling true 
measles, and urticaria may also occur. 

Secondary Vaccinations. — Secondary vaccinations may rarely occur 
from the accidental transfer of the vaccine virus from the local sore to 
some other part of the body; this transfer usually comes through the hand 
of the patient. The genital organs are the most common site of secon- 
dary vaccinations. The eye may also be inoculated. Accidental vaccinia 
may also occur in unvaccinated children suffering from eczema. In these 
cases generalized vaccinia may develop and the disease may terminate 
fatally. 

Complications. — The most common complication is a septic infection 
of the local sore by pyogenic microorganisms. As a result more or less 
serious cellulitis may occur, involving the tissues of the arm around the 
point of vaccination; even a general septicopyemia may result. Abscesses 
in the lymphatic glands of the axilla and neck may occur, especially in 
tuberculous children. Impetigo and erysipelas are rare complications. 
Syphilis and tuberculosis are perhaps never transmitted by vaccination. 
The latter disease, however, may be aggravated by vaccinia. Tetanus has 
been conveyed by vaccination; this, however, is a very rare occurrence, and 
could only happen where the animal producing the virus was suffering 
from tetanus. 

Revaccination. — A successful vaccination fully protects the individual 
from vaccinia and from smallpox for a more or less indefinite period of 
time. In some instances the immunity thus produced lasts throughout 
a long life-time ; as a rule, however, it begins to run out after five or six 
years, and from that time on the child becomes more and more suscep- 
tible to smallpox. During this period of partial immunity the individual 
may have smallpox in a mild form (varioloid). It is therefore advisable 
to follow the first vaccination by a second vaccination six or seven years 
later, and thereafter the individual should be vaccinated during every 
smallpox epidemic, if there has not been a successful vaccination within the 
last five years. Second vaccinations commonly run a mild course, and the 
local sore produced thereby gives little annoyance and is associated with 
no constitutional symptoms. An infected vaccination wound or other in- 
juries may present a scar resembling that produced by a successful vac- 



354 VARIOLA, VACCINIA, AND VARICELLA 

cination. The so-called typical scar should not, therefore, exempt individ- 
uals from vaccination during smallpox epidemics. 

Treatment. — In the care of the local sore two things are sought, first, 
to prevent traumatic injury, and, second, to prevent infection. Immediate- . 
ly following the operation of vaccination the wound should be covered 
with clean cotton or linen cloth. This should not be bandaged about the 
arm, as such a dressing drags the sore in the putting on and off of cloth- 
ing. A strip of clean cloth covering the sore may be held by adhesive 
plaster placed far enough away to not come within the zone of conges- 
tion produced by the sore. A cloth of this kind may be renewed every day 
and the vaccine wound dusted with boracic acid powder. If there is much 
itching carbolized vaselin may be used not on but around the wound. 
Oils, ointments and moist dressings to the sore are contraindicated as 
long as it remains dry and uninfected. The cloth for the protection of the 
wound may also be stitched to the undershirt, extending several inches 
above and below the point of vaccination, and this should be changed every 
day. This precaution is even better than changing the child's undercloth- 
ing, since a soft cotton or linen rag is less irritating to the vaccine wound 
than the material ordinarily used for underclothing. If the sore becomes 
moist and adheres to the rag, dusting powders are of service; among these 
aristol and chemically pure boracic acid are valuable. They should be 
applied frequently during the day and the sore protected by a light vac- 
cination shield, large enough not to injure it and so constructed, of wire 
or other material, that there will be a free access of air to the wound. If 
infection results in a cellulitis the patient should be confined to bed, all 
bandages removed and moist dressings of 1 to 1,000 bichlorid of mer- 
cury or 5 per cent, aluminium acetate, used. Vaccination shields are of 
special value in protecting the scab after the local inflammation has sub- 
sided. 

VARICELLA 

Varicella, or chickenpox, is an acute infectious disease characterized by 
a vesicular eruption which is commonly preceded by fever and other slight 
constitutional symptoms. In its early history it was confounded with mild 
forms of smallpox, with which it is now known to have no connection. 

Etiology. — Although the specific microorganism of this disease has not 
been discovered, it is known to be very contagious; only slightly second- 
ary to measles in this regard. It occurs in mild epidemics, spreading 
rapidly through schools, families and institutions. The facility with which 
it spreads among the susceptible members of confined communities shows 
that its contagious principle is readily carried by fomites through the air 
to all parts of the room, and that personal contact of the sick with the 
well is almost always followed by transmission of the contagion. That 
the disease is not readily conveyed from house to house and from institu- 
tion to institution is evidence that the contagion is short-lived and is per- 



VARICELLA 



355 



haps very rarely carried by a third party or by the clothing and other be- 
longings of the patient. There is also little doubt but that the period of 
great contagiousness lasts but a short time, probably only during the four 
or five days covered by the acute symptoms; after that there is little dan- 
ger of transmitting the contagion; otherwise the disease would be widely 
spread by convalescent patients, still carrying the scales and scabs of the 
eruption. Varicella is preeminently a disease of childhood. Perhaps 90 
per cent, of the cases occur in children under ten years of age. In adults 
and nurslings it is rare. 

Incubation. — By most writers this period is placed at about fourteen 
days; it may, however, be a few days longer or shorter, and Gregory 
states that it is less than one week. 

Symptomatology. — The onset is marked by a rise in temperature, asso- 
ciated with headache, nausea, 
and sometimes with chilly 
sensations. The fever preced- 
ing the eruption is slight, but 
later it may rise to 103° F. 
and in severe cases even to 
105° F. It lasts from two to 
six days, and is rather mark- 
edly renr'ttent. The head- 
ache, nausea and general dis- 
comfort disappear within 
thirty-six hours and there- 
after the patient is comforta- 
ble. 

The exanthem is the 
characteristic symptom upon 
which the diagnosis is made; 
it appears early and develops 
rapidly. In mild cases the 
constitutional symptoms may 
be so slight as to be over- 
looked, and attention is first 
called to the child's illness by 
the eruption. This makes its 
appearance first in widely 
scattered patches on the face 
and back, quickly spreading 
over the body and later in- 
volving the arms and legs. 
When the eruption is fully developed it is much more marked over the body 
than on the face; in well-marked cases the body may be almost covered while 
the face shows comparatively few vesicles. The eruption first appears as 
violet-pink macules, which later become small vesicles varying greatly in 




Fig. 58.- 



-Varicella Eruption on the 
Day. (Hecker and Trumpp.) 



Fourth 



356 VAKIOLA, VACCINIA, AND VAEICELLA 

size, from 1 to 10 mm., the average size being about 3 or 4 mm. These 
vesicles are filled with a clear fluid which later becomes cloudy; they are 
surrounded by a small erythematous zone. Within twenty-four or forty- 
eight hours they begin to dry up, and during this period of desiccation may 
appear slightly umbilicated; this umbilication is due to the drying process 
preceding scab formation. The small dark scab, which marks the site of 
the vesicle, may remain for two or three weeks before it finally falls off. 
The chickenpox eruption is characterized not only by the great variation 
in the size of the vesicles, but more especially by the fact that they appear 
in successive crops on the same parts of the body, so that where the 
eruption is most profuse the hand may cover chickenpox vesicles in 
every stage of development, including the tiny red macule, the 
matured vesicle and the desiccated scab. The skin eruption during its 
height is usually associated with itching; this symptom may continue 
for days. 

The enanthem may be of value in the differential diagnosis. It appears 
in the form of vesicles or more frequently as an erosion of the mucous 
membrane locating the site of a ruptured vesicle, and is surrounded by a 
pinkish-red zone. Following the. breaking of the vesicle the erosion is 
frequently covered by a thin white exudate. This eruption occurs most 
commonly on the soft and hard palate, but may also appear on the pillars 
of the pharynx, tonsils and rarely on the gums and tongue. The enanthem 
is coincident in appearance with the exanthem. Painful and distressing 
local symptoms may be produced by pocks in unusual places; in the ear 
they may produce earache, in the throat an irritating and harassing cough, 
at the mouth of the meatus urinarius painful urination, and in the vulva 
an uncomfortable swelling. 

Blood. — There is a moderate leukocytosis during the pustular stage 
with an increase of polymorphonuclears; no eosinophiles. 

Complications. — While the course of chickenpox in the vast majority 
of cases is very benign and the prognosis in uncomplicated cases is in- 
variably good, it should be remembered that it may be followed by serious 
complications. Tuberculosis is the most common. Bright's disease, gan- 
grenous dermatitis, adenitis and arthritis may rarely occur. 

Diagnosis. — The only disease with which chickenpox may be confused 
is varioloid. From this it may be differentiated by the fact that in 
chickenpox every stage of the eruption may be found on the same part of 
the body at the same time, while in smallpox the skin lesions on any part 
of the body are in the same stage of development. In chickenpox also 
there is greater variation in the size of the vesicles and they do not have 
the early shotty feel of the smallpox vesicle. As emphasized by Council- 
man the vesicular fluid of the chickenpox vesicle is contained in a single 
cell and not in a system of cells as in smallpox, so that a single pin prick 
at once flattens the chickenpox vesicle. The vesicle in Ghickenpox is never, 
as in smallpox, umbilicated, although it may appear slightly so during the 
stage of desiccation. The chickenpox vesicle runs its course in three days, 



ETIOLOGY 357 

the smallpox vesicle requiring a much longer time. The two diseases may 
also be differentiated by their characteristic enanthems. 

Immunity. — One attack, as a rule, confers lasting immunity, second 
attacks are extremely rare. 

Prophylaxis. — Patients suffering from this disease should be isolated. 
Tuberculous children should be especially guarded, as chickenpox may 
aggravate an existing tuberculosis. Because of the mildness of this in- 
fection it is practically impossible to continue the quarantine longer than 
one week. This, however, covers the period of greatest contagiousness. 

Treatment. — Chickenpox is a mild, self -limited disease, which in the 
great majority of instances requires little or no treatment. A prelim- 
inary laxative should be given and during the acute febrile stage the pa- 
tient should be confined to bed. The diet should be simple and composed 
largely of milk, cereals, purees of vegetables, bread and fruit juices. Al- 
buminous foods should be avoided or partaken of sparingly, the object 
being, as in the other acute infections, not to overtax the kidneys. Phen- 
acetin and antipyrin may be given to relieve the headache, reduce the 
fever, and make the patient more comfortable during the acute febrile 
stage, but these drugs should be used only when they are needed and not 
as a routine measure. Lanolin and carbolized vaselin may be applied to 
the skin to relieve the itching. Care should be taken to prevent the pa- 
tient from scratching the pocks, as this may result in infection and in the 
production of unsightly scars. 



CHAPTER XLII 

MUMPS 

(Epidemic Parotitis) 

Mumps is an acute infectious disease characterized by fever and by 
inflammation of the salivary glands, especially the parotids. 

Etiology. — The specific microorganism is unknown. The investiga- 
tions, however, of Leveran and Catrin are of importance since they found 
in the blood, in the parotid gland, in the testicle and in the edematous 
fluid diplococci which arranged themselves in twos and fours. Diplococci 
have also been found in Steno's duct and in abscesses of the parotid, com- 
plicating mumps. Further investigations, however, are required to show 
whether this organism is etiologically related to mumps. The specific 
cause is spread by the well coming in close contact with the sick. The 
poison cannot be carried any distance through the air, and is rarely trans- 
ferred by a third person. Such close contact is required for the spread 
of this contagion that there is little difficulty in confining it by quaran- 
tine regulations. I have on many occasions quarantined cases of mumps 
in the end room of a children's ward without having the infection spread. 



358 MUMPS 

In hospitals and in other institutions where a large number of children 
occupy the same room the disease spreads to children in neighboring beds 
rather than to children across the ward. The disease occurs in epidem- 
ics, little influenced by weather conditions, but they are slightly more 
common in winter than in summer. The severity of the disease and the 
degree of its infectiousness vary greatly in different epidemics. Instances 
are on record where one-half of the exposed children have contracted this 
disease. In milder epidemics not more than 20 per cent, of those exposed 
contract it. 

Age. — Comby reports a congenital case. The disease is almost un- 
known under one year and is very rare under two and over forty; sus- 
ceptibility increases up to the sixth year. The great majority of the cases 
occur between the sixth and fourteenth year of life. After this susceptibil- 
ity gradually diminishes, young adults about twenty years of age still 
being quite susceptible, but in old age the disease is almost unknown. 

Period of Contagion. — This lasts for three weeks dating from the be- 
ginning of the attack. The disease, however, may be contagious for a few 
days before the acute symptoms have developed, and in some instances it 
appears that the contagion may last for five or six weeks. It may be as- 
sumed that the period of greatest contagion is during the first week while 
the acute symptoms are present, and that it gradually diminishes during 
the next two weeks. 

Incubation. — Eighteen days is the average period of incubation, but 
it may vary from two to four weeks. 

Immunity. — One attack commonly confers immunity. Second attacks 
are unusual and third attacks rare. 

Symptomatology. — The child is fretful, languid, sleepless, loses its ap- 
petite, has a slight elevation of temperature with headache, backache, and 
a certain amount of stiffness and tenderness at the angle of the jaw. 
Shortly after the onset of these symptoms, usually in from one to three 
days, the swelling of the parotid gland appears, and there is localized ten- 
derness and an increasing stiffness in the movement of the jaw. The 
swelling appears between the angle of the lower jaw and the mastoid 
process. It gradually obliterates the intervening depression, rises and 
extends in front of the ear, involving the whole gland. The subcutaneous 
tissue surrounding the parotid not infrequently becomes infiltrated and 
edematous. This tumor mass, which is the characteristic sign of the 
disease, is tense and firm, does not pit on pressure, is located in front of 
the ear and extends downward, tilting the ear backward and extending into 
the neck. In some instances only one parotid is affected, but, as a rule, the 
other begins to swell three or four days later, so that in most instances 
the disease is bilateral, giving a peculiar squirrel-like appearance to the 
face; the neck, just under the ears, is wider than the face itself. 

The sub-maxillary and sub-lingual glands may also be involved, pro- 
ducing firm, resistant, tender, swollen masses. These glands may be af- 
fected after or before the parotids, or the disease may be wholly confined 



DIAGNOSIS 359 

to the sub-maxillary and sub-lingual glands. The swelling in the parotid 
gland gradually reaches its height in four or five days, remains about the 
same for two days and then rather quickly subsides, lasting in all from 
one week to ten days; in the bilateral cases this period may be slightly 
prolonged if one parotid is infected some days after the other. 

There is more or less pain and tenderness associated with the parotid 
swelling which may be aggravated by the taking of acids or spicy foods 
which may irritate the buccal mucous membranes. The pain is increased 
on opening the jaw. This causes the patient to keep his mouth partly 
closed in speaking and in taking food, and in unilateral cases to tilt the 
head slightly to the diseased side so as to relax the tension of the muscles. 
Sore throat is commonly complained of on swallowing and an examination 
of the mouth shows a swelling and congestion of the buccal mucous mem- 
brane around Steno's duct. The tonsils, soft palate and fauces are red 
and congested. 

The fever, which is one of the earliest symptoms, rises by the second 
day to about 102 °F. In severe cases it may reach 104° F. This continues 
for four or five days and falls to normal soon after the parotid swelling 
reaches its height. The fall in temperature may be postponed or inter- 
rupted by the involvement of other glands or by relapses which may occur 
during the period of apparent convalescence. 

Epistaxis may be a feature of the disease in certain epidemics. Slight 
enlargement of the spleen and external lymphatics may occur in severe 
cases. There may be a slight lymphocytosis in the early stages, and if 
orchitis occurs leukocytosis may be marked. 

The duration of mumps in uncomplicated cases varies from one to 
two weeks. Severe cases may last much longer, and mild afebrile cases 
may show acute symptoms for only a few days. 

Complications. — In childhood this disease runs a much milder course 
than it does in adults, and the complications so common and so much 
dreaded in the adult are rarely seen. For this reason excellent authorities 
have advised that children should not be quarantined from this disease, 
as it is much better for them to have it in childhood than to run the risk 
of having it in a more severe form in adult life. 

Orchitis, the most common and dreaded complication in adult life, 
sometimes occurs in boys between the ages of twelve and fourteen ; it rarely 
occurs earlier. This complication usually appears about the end of the 
first week of the disease. The testicle is very tender and may be swollen 
to two or three times its normal size. In the female ovaritis may occur. 
In both sexes there may be enlargement and tenderness of the breasts. 
Deafness is rare, but it may result from a complicating otitis media. 
Albuminuria is not infrequent, but nephritis is very rare in childhood; it 
occurs more frequently in adults. Suppuration of the parotid, paralysis 
of the facial and auditory nerves, pancreatitis and inflammation of the lac- 
rimal gland are almost unknown in childhood. 

Diagnosis. — Mumps must be differentiated from other forms of paro- 



360 SYPHILIS 

titis, and the physician should keep in mind the fact that inflammation of 
this gland from other causes is not very uncommon. It may occur as a 
complication of any of the acute infectious diseases, it may be a part of 
a general septic process, it may be secondary to stomatitis and catarrhal 
inflammation of Steno's duct. If these facts are kept in mind the differ- 
ential diagnosis of mumps can readily be made. 

Prognosis. — This is almost invariably good. In older children com- 
plications may leave more or less serious results, such as deafness and 
impotency. 

Prophylaxis. — It is difficult to isolate these cases except during the 
acute stage, but for a period of three weeks from the beginning of the 
disease they should not be allowed to return to school, go to children's 
parties, or otherwise come into close contact with other children. 

Treatment. — Mild cases require no treatment beyond confinement to 
the house for a few days. In the more severe cases the patient should be 
kept in bed for a period of eight or ten days covering the acute symptoms. 
During this time the mouth should be carefully syringed or washed out 
several times a day with a mild alkaline antiseptic. The parotid swell- 
ing should be treated with hot applications, which help to relieve the 
pain and discomfort. Ointments containing glycerin, belladonna and 
guaiacol are also recommended. Phenacetin or antipyrin with small doses 
of tincture of strophanthus are of value in relieving the pain and rest- 
lessness. Chloral hydrate is a valuable hypnotic in this disease, and 
should be given in proper doses at bedtime, and repeated, if necessary, at 
three or four-hour intervals to produce sleep. 

"It has been shown that urotropin is excreted through Steno's duct. 
On this basis it should be of value in the treatment of mumps. A series of 
cases of mumps in adults at the Cincinnati Hospital was treated with uro- 
tropin; none of these developed orchitis, although many of a control series 
treated without urotropin did. The urotropin cases ran a uniformly milder 
course than the others." (A. Friedlander.) 

Dietetic Treatment. — Acids and foods which irritate the mucous 
membrane of the mouth increase the pain and discomfort and should 
therefore be avoided. Since the patient may have difficulty in opening 
his mouth and cannot properly masticate his food, the diet should con- 
sist of milk, gruels, cereals, ice-cream, eggs, milk-toast and other soft and 
liquid foods. 

CHAPTER XLIII 

SYPHILIS 

Syphilis is an acute infectious disease, due to the spirochseta pallida. 
It may be acquired by direct contact or it may be congenital. The acquired 
form of the disease, so common in the adult, is comparatively rare in the 
child. The congenital form, which is the ordinary syphilis of infancy and 



ETIOLOGY 361 

childhood, is characterized by cutaneous eruptions, by general malnutri- 
tion and by destructive lesions of bones and internal organs. 

Etiology. — The specific cause of this disease is the spirochaeta pallida, 
first described by Schaudinn in 1905. This organism has been found in 
the various lesions of both the acquired and congenital forms of this disease, 
such as the initial sore, the mucous patches, the lymph glands, the skin 
lesions and syphilis of the internal organs. 

Acquired Syphilis. — Acquired syphilis in infancy and childhood 
presents the same clinical picture that it does in the adult. The initial 
lesion, which is followed by secondary and tertiary symptoms, is contracted 
by direct contact with the contagion. Denuded surfaces of skin or mucous 
membrane on the infant or child are inoculated with the specific micro- 
organism of this disease by coming in contact with the primary sore or 
mucous patches of an infected individual. In older children it may be 
communicated by sexual contact. Acquired syphilis, however, because of 
its comparative rarity and the sameness of the clinical picture which it 
presents to that of syphilis in the adult, requires no further consideration. 

Congenital Syphilis. — Congenital syphilis is essentially a disease of 
infancy and childhood, although its manifestations may continue in a 
modified form throughout the life of the individual. The clinical pic- 
ture of this form differs essentially from the acquired form and requires, 
therefore, careful clinical study. 

Congenital syphilis can be transmitted to the child only through the 
mother, and the virulence of the infection and the degree of syphilization 
of the fetus depend upon the virulence and stage of the disease in the 
mother. The most virulent infections occur at the height of the maternal 
secondary stage; as this stage passes into the tertiary, the infection of the 
fetus becomes less virulent and less certain. In the very early primary 
and the well-advanced tertiary stages the syphilitic taint may not be suffi- 
cient to produce syphilis in the infant. Previous treatment of the maternal 
parent may so materially modify the infection of the offspring that it 
may show no signs of the disease, but the recurrence of symptoms and re- 
lapses following intermittent treatment in the mother may be followed by 
evident syphilis in subsequent children. 

For many years it was very generally believed that syphilis could be 
transmitted to the child from either father or mother or from both. It 
was thought that the father could infect the ovum directly with his syph- 
ilized sperm and the mother escape subsequent infection through the 
placental barrier. It was frequently observed that these children with 
their mucous plaques could suckle at the breast of their mother with 
impunity, and the mother escape every sign of infection; a wet nurse, 
however, not previously infected with syphilis might be infected by these 
infants. It was therefore believed that the mother escaped infection and 
became immunized against syphilis through her syphilitic offspring 
(Colles' law). It was also observed that a healthily conceived child whose 
mother became infected at some period during parturition could be born 



362 SYPHILIS 

healthy and escape infection through the same placental barrier, and would 
remain immune against syphilis from maternal and other sources (Prof eta's 
law). 

The Wassermann reaction has demonstrated that both infant and 
mother are syphilized under these conditions. The circulation of both 
mother and child is extremely intimate, the placenta presenting no barrier 
against the infection; a mother who produces a syphilitic child must of 
necessity share the infection, and her immunity and that of her child is 
apparent, not real. If the infected mother is suffering from severe mani- 
festations in the secondary stage, the disease would probably be transmitted 
in a severe form, resulting either in the death of the fetus or in advanced 
congenital syphilis. 

Syphilis cannot be transmitted to the third generation. The physical 
defects, however, resulting in a weak progeny may be transmitted, but 
the specific lesions of this disease do not pass to the third generation. 

Pathology. — Post-mortem examination of a macerated syphilitic fetal 
corpse not uncommonly fails to show any characteristic anatomical changes 
of this disease. This is especially true if death occurs before the fourth 
month of fetal life. After the fourth month the characteristic lesions 
commence to make their appearance, osteochondritis and enlargement of 
the spleen, liver, kidneys, pancreas, thymus, and indurative changes in the 
lungs occur with increasing frequency. Skin lesions are not commonly 
found until near the end of the normal period of uterogestation. 

Syphilitic osteochondritis is the earliest, most common and most char- 
acteristic lesion of congenital syphilis. It occurs principally in the long 
bones at the junction of the shaft with the epiphysis, and the inflammation 
may result in the dissolution of this junction, thus separating the epi- 
physis. The enlargement and induration of the spleen, liver, kidneys, 
lungs and pancreas, so commonly present, are due to a general round- 
celled infiltration and connective tissue proliferation. 

Symptomatology.' — Syphilis is one of the most common causes of re- 
peated abortions. Following an abortion, which may occur as early as the 
third or fourth month, producing a dead and macerated fetus showing no 
distinctive syphilitic lesions, the same woman impregnated by the same 
man may, one or two years later, in the seventh or eighth month of utero- 
gestation give birth to a dead infant, showing an osteochondritis of the 
long bones, enlargement of the spleen and liver, fatty degeneration of the 
placenta, round-celled perivascular infiltration of the umbilical cord and 
other characteristic signs of congenital syphilis. One or two years later 
the same mother may give birth to a still-born infant at term or to one 
that lives but a few days. In this infant, in addition to the signs just 
noted, the kidneys, lungs, pancreas and other internal organs may show 
characteristic syphilitic lesions and the skin may be covered with a large 
bullous eruption known as syphilitic pemphigus. Still later this mother 
may give birth to an infant apparently normal at birth which, within the 
first three months, develops a syphilitic coryza followed by other signs 



SYMPTOMATOLOGY 363 

of congenital syphilis, and later in her life she may give birth to an 
apparently normal child which never shows any sign of syphilis. This 
chain of clinical manifestations illustrates the fact that the power of 
transmitting the syphilitic poison is gradually lost by the parents, and 
also that in direct proportion to the potency of the poison in the parents, 
the earlier and the more virulent will the manifestations be in the fetus, 
thus producing successively in the same mother abortions, premature 
births, still-births at term, syphilitic weaklings that live but a few days, 
apparently normal infants that later develop syphilis, and finally children 
in whom no signs of syphilis ever develop. 

From what has been said it is evident that the earlier the manifesta- 
tions occur after birth the more severe the disease will be. Even in very 
early syphilis the symptoms are not, as a rule, present at birth, but in 
quite a large percentage of the cases the disease manifests itself during 
the first or second week. In these early cases the infant is profoundly 
malnourished, and as the disease progresses it becomes more and more 
wasted, its dried skin hanging in folds, its wizened face having an aged 
appearance, and a well-marked coryza discharging an irritating fluid 
excoriates the upper lip. The lips are cracked, the corners of the mouth 
fissured, and mucous patches may be found in the mouth and in the anus. 
A bullous eruption appears on the palms of the hands and the soles of 
the feet. Tenderness and swelling may also be present at the ends of 
the long bones near the joints of the arms and legs. External and in- 
ternal hemorrhages may occur from mucous membranes. In the worst 
cases, as the disease progresses, the emaciation becomes more extreme and 
the child dies within a few weeks. Fortunately, however, in the great 
majority of cases the clinical manifestations do not develop until after 
the middle of the second week of life, and from this time until the 
end of the sixth week is the most common period of onset; it very 
rarely develops after the third month. These cases are not so 
violent in their clinical manifestations and are much more amenable to 
treatment. 

Coryza, or rhinitis, is the commonest and most characteristic symp- 
tom, and, as a rule, marks the onset of the symptom-complex. The mucous 
membrane of the nose is intensely irritated, swollen, and discharges a 
mucopurulent fluid, which may be tinged with blood. This discharge is 
irritating in character, producing an eczema of the upper lip. Crusts form 
in the nasal cavity, which have a tendency to retain the discharge, and 
this retained discharge, as the air passes through it, produces a snuffling 
sound which has been characterized as the "snuffles." With the formation 
of crusts and the retention of discharges the mucous membrane of the 
nose becomes more or less disintegrated, and the cartilage and bones of 
the nose become involved. If this process continues marked nasal de- 
formities may result. The nasal septum may be perforated and the bridge 
of the nose may be broken down, producing the saddle nose and other de- 
formities. A severe coryza so obstructs the nasal passages as to materially 



364 SYPHILIS 

interfere with the infant's nursing. A coexisting laryngitis may produce 
hoarseness ; this is a very suggestive symptom. 

Skin Lesions. — Vesicular eruptions are very rare in hereditary syph- 
ilis^ except the large vesicular or bullous eruption known as syphilitic 
pemphigus, which occurs in the severe forms of this disease found during 
the first weeks of life. This eruption may occur over the body, but is 
commonly confined to the palms of the hands and the soles of the feet, and 
is composed of large blebs from an eighth to one-half inch in diameter, 
filled with bloody fluid, and the intervening skin where the eruption is 
profuse is indurated and dark red in color; where the blebs are isolated 
a zone of such tissue surrounds them. This eruption not uncommonly 
causes complete exfoliation of the skin on the palms of the hands and 
the soles of the feet and is most ominous in its significance, as it occurs 
only in the worst cases. It is not to be confounded, however, with non- 
syphilitic pemphigus neonatorum, due to infection, and which may occur 
in well-nourished infants. This eruption is not surrounded by a reddish- 
brown base, and does not select the palms and soles as its favorite site. 
Hochsinger has described another condition of the skin which is charac- 
teristic of hereditary syphilis and does not belong to the acquired form. 
The skin is diffusely infiltrated, thickened and feels dense and firm to 
the touch, has a dark red, shiny appearance, getting darker in color as it 
gets older. This diffused infiltration of the skin is commonly associated 
with other eruptions, very like certain of the eruptions that are found in 
the acquired form" of syphilis. These eruptions, like the pemphigus erup- 
tion previously described, may be superimposed upon this dark red in- 
durated skin. Among them the maculopapular syphilide is the most com- 
mon. This occurs as small, round, rose-red spots which, as they grow 
older, become more or less copper-colored, and are elevated above the sur- 
face of the skin. A distinctly papular eruption may be associated with 
this macular eruption, the small papules marking the center of the rose- 
colored macules, or appearing as a separate exanthem. A pustular or a 
papulopustular syphilide may also appear. The pustular eruption occurs 
most commonly on the face, thighs and buttocks. Mixed eruptions are 
very common in hereditary syphilis, and the macular, papular and pus- 
tular syphilide may all be present at the same time. 

Infiltration of the skin of the face may give it a tense, glittering 
appearance, and the same condition may exist about the region of the 
anus. This leads to cracking of the skin and the formation of radial 
-fissures about the corners of the mouth and the anus, which produce a 
more or less characteristic appearance and one of the most valuable of 
diagnostic signs. Ulcers and mucous patches may develop in these fis- 
sures, greatly increasing the irritation, and papular excrescences may de- 
velop about the rectum, producing small tumors called condylomata. The 
infiltration of the skin about the finger nails produces paronychia. This 
may be an active ulcerative process about the root of the nail, or it may 
be a lower grade of inflammation unaccompanied by purulent discharges. 



SYMPTOMATOLOGY 



365 



The nail may be destroyed or distorted. This same process affecting the 
hairy parts, such as the eyebrows and the scalp, may result in the complete 
destruction of hair in these regions. Complete baldness, however, is not 
very common, especially in early infancy. 

Bones. — The long bones may be tender and enlarged near their ex- 
tremities, at the junction of the shaft and the epiphysis. These sensitive 
swellings occur with special frequency at the lower epiphyses of the hu- 
merus and femur, and separation of the epiphyses may result, as shown by 
increased motion and crepitus. Associated with these symptoms there 
may be almost entire loss of motion of the affected limb. This is spoken 
of as syphilitic pseudo-paralysis, and is, according to Hochsinger, purely 
a muscular manifestation, due to severe periosteal involvement at the 
point of muscular attach- 
ment. According to the 
same authority syphilitic 
phalangitis primarily in- 
volves the first phalanges 
of either the fingers or the 
toes. The fingers are most 
commonly affected and the 
index finger is its favorite 
site. Following the in- 
volvement of the proximal 
phalanx, the middle pha- 
lanx of the same finger or 
toe may be involved. The 
swelling thus produced is 
chronic in character, coni- 
cal in shape, painless, 
tense, and glossy. The 
soft parts are but slightly 
involved, and ulceration 
rarely occurs. 

The teeth are delayed, imperfectly developed and decay early. The 
skull presents more or less characteristic rachitic changes with its open 
fontanels and enlargement of frontal and parietal eminences, and cranio- 
tabes may occur. 

General Malnutrition. — The degree of malnutrition will depend 
largely upon the severity of the disease and the food of the infant. In 
the severe cases developing soon after birth malnutrition is profound 
and, as previously noted, commonly progresses to a fatal termination. In 
the later and less severe cases the child at birth may be fairly well nour- 
ished and, if it have the advantage of good breast milk and early and 
proper treatment, it may continue in a fair state of nutrition. Syphilitic 
babies, however, as a rule, have feeble digestive capacity, and those that 
are artificially fed show a more or less marked malnutrition, which may. 




Fig. 59. — Syphilitic Dactylitis; Infant Sixteen 
Weeks Old. (Max Dreyfoos.) 



366 ' 



SYPHILIS 



even in the cases that develop some weeks after birth, become very pro- 
nounced. Malnutrition is associated with more or less marked anemia, 
which may be characterized in severe cases by a diminution in the amount 
of hemoglobin and in the number of red blood corpuscles. Many of the 
red blood corpuscles are nucleated and vary greatly in size, microcytes 
and megalocytes being present. There is also a more or less marked 
leukocytosis with a preponderance of myelocytes. Eosinophiles are also 
present. General lymph-node enlargement does not, as e, rule, occur in 
early hereditary syphilis. 

Brain. — Disease of the brain and its membranes may produce hydro- 
cephalus, idiocy and hemiplegia. 

Spleen. — This organ is very much enlarged and is easily palpated in 
the syphilis of early infancy. The earlier the disease develops the more 
pronounced is this sign. 

Liver. — The liver may be enlarged, extending well below the margin 
of the ribs; jaundice may occur. 

Kidneys. — Acute nephritis may occur early in the disease and yield to 
specific treatment. It is also a late manifestation, occurring shortly before 
death. In these cases the nephritis may be a terminal lesion, resulting 
from the intestinal and general toxemia. 

Late Hereditary Syphilis. — Late hereditary syphilis develops later 
in the life of the child, usually after the fifth and sometimes as late as 
the twelfth or fifteenth year. These cases present the symptoms of ordinary 
tertiary syphilis. They are commonly believed to be true hereditary syph- 
ilis, the symptoms of which, for some unexplained reason, were not clearly 
manifested in infancy. The small minority of the cases, however, may 
be due to an overlooked syphilis acquired earlier in life. In calling atten- 
tion to these cases Hutchinson described the following triad of symptoms 
which are more or less characteristic: First, the notching of the central 
incisor teeth; second, an interstitial keratitis; and third, sudden deafness 
without apparent local cause. 

Hutchinson s Teeth. — The central incisors of the secondary teeth have 
a large, single, crescent-shaped notch occupying the center of each tooth. 

The teeth themselves are 
rounded and taper from a 
broad base to a constricted 
cutting edge, presenting a 
peg-like appearance. They 
are inclined toward each 
other, as a rule, but occa- 
sionally they may diverge. 
When present, although not 
absolutely pathognomonic of 
syphilis, they are, when taken 
in connection with other symptoms, among the most valuable signs of this 
disease. They are absent, however, in a majority of the cases. 




Fig. 60. — Hutchinson's Teeth. 



DIAGNOSIS 367 

Interstitial 'keratitis may be associated with corneal opacities and with 
inflammation of the iris, but, as a rule, is not accompanied by an active 
conjunctivitis. This symptom is also especially valuable in its association 
with other symptoms of hereditary syphilis. 

Sudden loss of hearing unaccompanied by apparent disease of the ear 
is very suggestive of hereditary syphilis. Loss of hearing and mastoiditis 
may also occur in this disease, resulting from a low grade of chronic 
otitis. 

Periostitis of the tibia, ulna, radius, and humerus may occur. The 
tibia is most commonly affected, and as a result a long, narrow, tender 
swelling is presented on its anterior surface. 

The nose, pharynx and palate may be involved in destructive ulcera- 
tions, causing necrosis of the underlying bones, and marked deformities 
may result. In severe cases the ulceration in the nasopharynx may pro- 
duce widespread destruction, of the tissues, causing the bridge of the nose 
to give way, forming the so-called saddle nose. 

Gummatous ulceration may occur over the shin, especially of the face 
and legs, producing large round ulcers with indurated borders. These ul- 
cers have a tendency to group themselves and in their healing produce 
large radiating scars which are more or less characteristic. This is espe- 
cially true when these ulcers involve the mucous membrane of the lips. 
Hochsinger says: "An absolutely positive proof of former hereditary 
syphilis is found in the radial scar formation of the lips/' 

The spleen is almost always notably enlarged, more so than any of the 
other internal organs; the liver may be increased in size. There is a 
more or less notable enlargement of the external lymph nodes; in this 
particular late hereditary syphilis differs from the infantile form. 

General malnutrition and retarded and perverted development are 
among the notable symptoms occurring in late childhood about the period 
of puberty. 

Diagnosis. — The chief difficulties in the differential diagnosis of early 
syphilis are presented by infantile marasmus and tuberculosis. In infan- 
tile marasmus the malnutrition commonly occurs later in the life of the 
child, and there is perhaps no history of previous abortions and snuffles. 
Enlargement of the spleen and characteristic syphilitic skin eruptions are 
absent, while on the other hand there is perhaps a history of gastrointes- 
tinal disease or other causes which may explain the marasmus. 

Tuberculosis of the bones of the finger and of the long bones of the 
arm and of the leg may be mistaken for syphilis. The differential diag- 
nosis may here commonly be made by the family and personal history of 
the child, supplemented by the tuberculin skin test. Tuberculous dactylitis 
involves not only the bone, but the soft parts as well, producing a tender 
and more or less acute inflammation which tends to suppuration and ul- 
ceration of the soft parts. In these particulars it differs from the syph- 
ilitic dactylitis previously described. In the long bones tuberculosis in- 
volves the epiphyses rather than the shaft of the bones, and the resulting 
25 



368 SYPHILIS 

inflammation affects the joints, while in syphilis the joints are not com- 
monly involved and the diaphyses of the long bones are the sites of the 
inflammation. 

The Wassermann- Neisser-Bruck reaction for syphilis is the most exact 
method of differential diagnosis. To make this test accurately, however, 
requires special training and laboratory equipment. A detailed descrip- 
tion of its technique would, therefore, be out of place here, but a brief 
allusion to its fundamental principles and their practical application will 
not be amiss. 

Substances called antibodies are formed in the serum of every syph- 
ilitic who in any way reacts against the infection. They are constantly 
present in the vast majority of the untreated or inadequately treated cases 
of syphilis in all stages of the disease, and for a period of years. These 
substances preclude hemocytolysis or the solution of the sheep's corpuscles in 
the Wassermann reaction. This is a specific reaction for syphilis, and 
when positive is an unfailing evidence of the presence of the disease. It is 
frequently absent in well-defined cases of severe or malignant syphilis, and 
in such cases there is evidence of the failure of the system to properly 
react against the ravages of the affection. It gradually disappears in 
cases that have received adequate medication, and in such cases it becomes 
the best scientific evidence we possess that the disease is under control. 
Hereditary syphilis, according to Ledermann and numerous others, will 
often show a positive Wassermann reaction into early adult life or later. 

In view of the now generally accepted fact that a syphilitic infant is 
of necessity progeniated from a syphilized mother with active syphilis, 
a Wassermann examination of the mother confirms or rules out the diag- 
nosis of syphilis in a suspected infant. This has a practical application 
inasmuch as the blood for the examination can be more easily obtained 
from the mother. The blood may be secured by allowing it to flow through 
an 18-gage needle into a sterilized centrifuge tube from one of the large 
veins of the forearm, after an Esmarch bandage has been placed above the 
elbow. In an infant the blood is most conveniently collected under less 
favorable and less aseptic conditions by a scarification below the scapula. 

Prognosis. — The earlier the symptoms appear the worse the prognosis. 
The more severe cases, and this includes a large percentage of the total 
number, die in utero, and of those that are born alive the prognosis is 
almost uniformly bad when the symptoms make their appearance during 
the first week. These two classes include in the neighborhood of 50 per 
cent, of all cases. In the milder cases, in which the symptoms appear af- 
ter the second week, the prognosis under proper treatment is good so far 
as life is concerned. The vast majority of these respond quickly to the 
specific medication of this disease, and their subsequent chances for life 
will depend largely upon their hygienic surroundings and their dietetic 
treatment. Relapses occur in a large percentage of these cases, because of 
insufficient treatment. It is also probable that hereditary syphilis usually 
results in more or less permanent physical deterioration. The degree, 



TEEATMENT 369 

however, of this deterioration can be very materially modified by early and 
persistent treatment. 

Prophylaxis. — Individuals affected with syphilis should not marry for 
four years after the beginning of the disease, and then only after at least 
two years of well-directed medical treatment. If married, conception 
should be prevented during the two or three years necessary to control 
this disease. If, however, conception occurs, the mother should have 
antisyphilitic . treatment throughout the entire period of pregnancy. In 
this way it is possible to largely protect the fetus and cause the mother to 
give birth to an apparently healthy child, which later may or may not 
show signs of this disease. Special stress should be laid upon the value 
of giving the mother antisyphilitic treatment in all cases where this disease 
is suspected. This is especially important if the mother at any time 
during her life has ever been actively syphilitic. With the birth of a 
syphilitic infant the nurse or parents should be impressed with the fact 
that the infant has an infectious disease which may be communicated to 
others. Children are in special danger from kissing and from using the 
same food utensils. The danger also of infection to a non-syphilitic wet- 
nurse from mucous patches in the mouth of the infant should be explained. 
The danger from the contagion of hereditary syphilis has no doubt been 
greatly exaggerated, because of the dread of this disease. But although 
this danger may be slight, there is no reason why every possible precau- 
tion should not be taken to prevent the infant from contaminating others. 

Treatment. — Dietetic Treatment. — The dietetic treatment of infan- 
tile syphilis is most important. Since these infants have feeble digestive 
capacities and at the same time have a more or less marked malnutrition 
to overcome, it is all-important that they should, if possible, be given 
breast milk. Fortunate it is, therefore, for the syphilitic infant that its 
mother may nurse it with comparatively little danger to herself. The 
mother's milk, therefore, should be used in every instance w T here it is pos- 
sible, and when insufficient should be supplemented by modified milk for- 
mulas suitable to the age and digestive capacity of the infant, and these 
supplementary feedings should be carried out under the principles outlined 
under Mixed Feeding. That is to say, the infant is to be given the 
breast milk at every nursing, and this is to be supplemented, if necessary, 
by the bottle. In those cases where mother's milk is not available it may 
sometimes be necessary in order to save the life of the infant to employ 
a non-syphilitic wet-nurse, having her bring her own infant with her and 
giving the syphilitic infant such breast milk as can be obtained by pump- 
ing from the breast of the wet-nurse. Under no conditions, however, 
even though the mouth of the syphilitic infant be apparently normal, 
should it be allowed to nurse the milk directly from the breast of the non- 
syphilitic wet-nurse. Great importance is here laid upon the value of 
breast milk in the treatment of this disease, because I believe that it is 
necessary to complete success in the treatment of the great majority of 
these cases. When, however, the breast milk is not available the infant is 



370 SYPHILIS 

to be fed according to the rules laid down for weaklings under Chronic 
Intestinal Indigestion. 

Medical Tkeatment. — Mercury. — Mercury is a specific for this disease, 
so much so that a symptom group in an infant over three weeks of age 
that fails to respond to this treatment is not syphilitic. This therapeutic 
test is therefore a diagnostic measure of great importance. 

Inunction of Mercury. — In the young infant mercury may perhaps be 
given more satisfactorily by inunction than by any other method. For this 
purpose unguentum hydrargyri mixed with anhydrous lanolin should be 
used. A quantity of this ointment sufficient to represent ten or fifteen 
grains of the mercurial ointment is to be used for each inunction. The 
site of the inunction should be prepared by carefully cleansing with warm 
soap and water and then, after thoroughly drying the skin, the mercurial 
ointment is to be gently rubbed in for from five to eight minutes, the 
operator using rubber gloves in making the inunction. In beginning the 
routine treatment one application is made daily, and the sites commonly 
selected are the inner surfaces of the thighs, the sides of the chest beneath 
the axilla, the lower abdomen and, if necessary, the flexor surfaces of the 
lower arms and legs. It is better to rotate in using these various sites for 
inunctions, as the continuous application of the ointment to the same por- 
tion of the body day after day may produce an irritation of the skin. In 
the average infant the specific therapeutic action of mercury can be more 
quickly and more satisfactorily obtained by inunctions than by any other 
method, and its administration in this way is accompanied by no gastro- 
intestinal disturbance. These facts should make the inunction method 
the method of election. It should be remembered, however, that satis- 
factory results can be obtained only by carefully following the technique 
as above outlined. The mercurial ointment should be diluted with lanolin 
and should be thoroughly rubbed into a clean, dry shin. Following this 
application the child may have a bath and the unsightly ointment removed 
from the skin. This is sometimes necessary in the treatment of these 
cases in private families where it may be important that the nature of 
the treatment should not be known to all the members of the household. 

Internal Administration of Mercury. — The administration of mercury 
by the mouth is by far the most popular method. The vast majority of 
cases in private practice are treated in this way, because almost as good 
results can be obtained by this method and because it is so easy to give 
mercury in this manner. For this purpose four preparations are in com- 
mon use, mercury with chalk, calomel, bichlorid of mercury and proto- 
iodid of mercury. Of these mercury with chalk is the favorite with the 
majority of English and American pediatricians. It may be given in from 
one-half to one-grain doses two or three times a day to young infants. The 
size of the dose may vary with the results obtained and with the condition 
of the gastrointestinal canal. If small closes are being given (y 2 grain) 
and the symptom group does not yield readily to treatment, the doses are 
to be gradually increased to 1 or 1% grains, and in oldar children to 2 



TREATMENT 371 

or ^V-2 grains. When the symptom group has been controlled it is better 
to return to the smaller doses for the long-continued treatment of the 
disease. This rule applies in the administration of all of the mercury 
preparations whether they be given by the mouth or by inunction. The 
larger dose that is necessary for the quick control of the early symptoms, 
is from one-third to one-half too large for the continued administration of 
this drug over long periods of time. The only advantage that the mercury 
with chalk has over the bichlorid and protoiodid is that it commonly 
produces less gastrointestinal disturbance and is therefore more suitable 
for long-continued use. This applies only to infants. 

The bichlorid of mercury may be given to infants in from 1/150 to 
1/200 of a grain, well diluted, two or three times a day. The total quan- 
tity administered in twenty-four hours should vary from 1/100 to 1/40 
of a grain. The larger dose perhaps being required to control the acute 
s}^mptoms, and the smaller dose to be used later for continuous adminis- 
tration. The protoiodid of mercury is used very largely by the German 
school of pediatricians, who believe that better results are obtained from 
this preparation than from any other. It may be given in doses of 1/60 
of a grain three times a day. 

Calomel is a remedy of great value in beginning the treatment of 
hereditary syphilis, and it is asserted by some authorities that the initial 
specific action of mercury can be obtained more quickly with calomel than 
with any other preparation of this drug. It may be given in 1/10-grain 
doses at three or four-hour intervals. 

Comparative Value of the Various Mercurial Preparations. — In begin- 
ning the treatment it is perhaps advisable to commence with calomel in 
1/10-grain doses at three-hour intervals. This medication may be con- 
tinued for four or five days, or until decided laxative action has been pro- 
duced. The calomel should then be discontinued and followed by mer- 
curial inunctions for weeks and possibly for months, until the syphilitic 
symptoms are under control and the nutritional problems have been largely 
solved. Then mercury with chalk may be used for the long-continued 
mercurial course, which is to extend with interruptions over a number 
of years, but during this time, if gastrointestinal disturbances develop and 
the infant's nutrition is thereby threatened, inunctions are again to take 
the place of mercury by the mouth. In older infants and children the 
bichlorid or protoiodid of mercury may be substituted for the chalk mercury 
and the mercurial ointment. 

lodin. — Iodin is also of great value in the treatment of hereditary 
syphilis. It may be given in the form of iodid of potassium, iodid of 
sodium and iodonucleoids. The iodonucleoids will not disturb the stomach 
and are therefore of special value in young infants. It may be combined 
with equal parts of saccharated pepsin or milk sugar and given in 1 or 2- 
grain doses three times a day ; this may be increased 1 grain for each year 
of life up to four years. Iodid of potassium dissolved in milk or essence 
of pepsin may be administered to infants in 2-grain doses three times a 



372 SYPHILIS 

day. In children five or six years of age this dose may be increased to 5 
or 10 grains. The iodid of potash is on the whole the best form for 
administering iodin in these cases. But if it should cause gastric disturb- 
ance iodonucleoids may be substituted. The iodids are especially indi- 
cated in late hereditary syphilis, but they may also be indispensable in the 
treatment of infantile syphilis when gummatous ulcerations and bone le- 
sions are present. 

Duration of Treatment. — It has for many years been my practice to 
give mercury with short interruptions during the first year, and for about 
half the time during the second year. After the second year, as a matter 
of routine, a course of iodids should be occasionally administered to 
alternate with a course of mercury, and this should be continued until the 
child is four or five years of age. These courses should be of six weeks' 
duration and should be given only two or three times during the year. 
After the fifth year the treatment should be resumed on the appearance of 
chronic obscure symptoms of any kind. If at any time pronounced and 
active symptoms of syphilis reappear, vigorous and prolonged antisyph- 
ilitic treatment must again be instituted. The long-continued interrupted 
use of mercury and the iodids produces no bad results on the teeth or 
other developing structures. 

Salvarsan. — Salvarsan has proved very efficacious in the treatment of 
congenital syphilis. The mortality of this disease in the new-born has 
been materially reduced by the introduction of this remedy. Under it 
the gain in weight and marked improvement in general appearance of the 
infant have been as noteworthy as the rapid disappearance of active symp- 
toms. The administration of this remedy to infants is attended with tech- 
nical difficulties. The intravenous and deep muscular injections with al- 
kaline solutions are impracticable. The freshly precipitated, carefully 
neutralized salt of salvarsan must be injected subcutaneously. These in- 
jections are fairly well tolerated, although they produce painful infiltra- 
tions and occasionally form abscesses and indolent ulcerations of the over- 
lying skin. 

Six decigrams of salvarsan, under careful aseptic precautions, are dis- 
solved in a clean mortar with thirty-five drops of sterile 10 per cent, 
sodium hydroxid solution ; this is then diluted up to 12 c. c. with normal 
salt solution. Then two to six grams varying with the age, weight and 
development of the child (one to ten years, one to three decigrams of sal- 
varsan) are drawn off with a sterile pipette into a second sterile mortar. A 
few drops of concentrated glacial acetic acid are then added with gentle 
stirring until the color is changed from red to light yellow, and neutrality 
is established; this can be determined by means of sterile litmus paper. 
It is then diluted to about 10 c. c. with sterile normal salt solution, trans- 
ferred to a centrifuge tube, and centrifuged for five minutes. The clear 
supernatant liquid is then carefully drained away and the residue, after 
it is again diluted with 5 to 10 c. c. of sterile normal salt solution, is 
transferred to a syringe and injected subcutaneously under the scapula. 



ETIOLOGY 373 

In view of the fact that the administration of salvarsan is occasionally 
attended with relapses, it is advisable, in the absence of careful Wasser- 
mann control, to supplement the administration of this remedy with inter- 
mittent treatment along the lines of the older accepted methods. It is also 
advisable not to repeat the salvarsan under a period of at least three or 
four months. 

Local Treatment. — Local treatment of syphilitic ulcerations demands 
the careful cleansing with antiseptic washes and the use of a dusting 
powder composed of equal parts of calomel, subnitrate of bismuth and 
oxid of zinc. 

CHAPTER XLIV 

TUBERCULOSIS 

Etiology. — Tuberculosis is a contagious disease caused by the bacillus 
tuberculosis of Koch. It may be general, but is commonly more or less 
localized, there being one or more foci of infection. It has a great predilec- 
tion in childhood for the lymph nodes, bones, and serous membranes, but 
no part of the body is exempt from attack. 

There are a number of fairly distinct types of tubercle bacilli ; of these 
we are especially interested in the human and bovine, since they may pro- 
duce tuberculosis in man. The human type is the most common cause of 
all forms of tuberculosis in the child as it is in the adult, but bovine tu- 
berculosis is relatively much more common in children, and is not an in- 
frequent cause of this disease in the cervical and abdominal lymph nodes 
and in the peritoneum. The human type is the usual cause of the more 
virulent forms of tuberculosis, while the bovine type, as a rule, produces 
a milder form of this disease. 

Contagion. — Contagion is the all-important factor in the spread of 
tuberculosis. Tubercle bacilli are discharged from the body of a tubercu- 
lous individual in a moist state, in the sputum, the milk, the feces, the 
urine, and in the purulent discharges from tuberculous abscesses and ul- 
cerations. Of these various discharges the sputum is by long odds the most 
important agent in spreading the infection, and for this reason the pul- 
monary form of tuberculosis is the chief source of contagion. The danger 
from tuberculous sputum is very great in both the moist and the dried 
state. The dried bacilli are much more widely disseminated than the moist 
bacilli, but the latter are much more active and virulent and a smaller 
dosage is therefore required to set up an active tuberculosis. In their moist 
state the tubercle bacilli are thrown in a fine spray for a distance of eight 
or ten feet by coughing, and may thus be inhaled by those who come within 
the range of this infection. In this manner and also by the careless 
disposal of the expectoration, the clothing and surroundings of the patient 
may become infected; handkerchiefs, wearing apparel, carpets, hangings 
and bed-clothing may be carriers for a short time of the bacilli in a moist 



374 TUBERCULOSIS 

state, and therefore a source of great danger, especially to infants and young 
children who spend a great portion of the time in such contaminated 
apartments. Their milk and other food, which is too often prepared in 
such surroundings, may become contaminated, and act as a vehicle for 
carrying the tubercle bacilli into their intestinal canals. Another danger 
from the moist sputum lies in the fact that flies and other insects may 
be a means of transferring bacilli to remote parts of the house and pro- 
ducing food contamination. Infants with the inherent instinct which they 
have of putting everything into their mouths are in special danger, since 
their toys and other foreign bodies with which they come in contact may 
carry into their mouths the moist tubercle bacilli. 

But after all the greatest danger in 'the spread of tuberculosis lies in 
the fact that the slender, rod-shaped bacillus of this disease is small and 
light enough to be carried short distances in a dried state by dust, or other 
foreign particles put in motion by currents of air, and thus be inhaled or 
produce food contamination. This in fact is an ever-present danger in 
public conveyances and in buildings now housing or that have housed tu- 
berculous patients. 

Next to sputum, milk contaminated with tubercle bacilli is the most 
potent factor in the spread of this disease. There is no longer any doubt 
but that milk from tuberculous cattle may be a source of danger, especially 
to infants, and the milk of the tuberculous mother may also be a carrier 
of tubercle bacilli. But in milk the greatest danger comes from localized 
tuberculous disease of the udder of the cow, or some other method of out- 
side milk contamination, rather than through the excretion of tubercle 
bacilli in milk. 

The urine, the feces and purulent discharges from tuberculous patients 
may be sources of infection, although this danger is believed to be slight 
because of the great dilution of the bacilli and because of the manner in 
which these discharges are ordinarily disposed of. 

Portals of Entry. — Tuberculous infection enters the body through the 
nasopharynx, the bronchial mucous membranes and the digestive tract. 
This latter route is much more common in the child than in the adult. The 
passage of tubercle bacilli through mucous membranes may be effected 
without producing injury or disease of the parts through which they pass. 
The accidental contamination of vaccination, circumcision and other fresh 
wounds can only occur where gross carelessness leads to direct inoculation, 
and this is fortunately a very rare occurrence. 

Exposure. — Tuberculosis is such a pandemic disease that practically 
every individual is exposed many times to its contagion. But this does 
not militate against the fact that the greatest danger comes from repeated 
exposure to the contagion in places especially infected with tubercle bacilli. 
In other words, one may say that, other things being equal, the danger 
of contracting tuberculosis is in direct proportion to the frequency and size 
of the dose of the contagion. This is a fact that should be impressed with 
especial force on the minds of the laity, since to them the contagion is 



ETIOLOGY 375 

not apparent, inasmuch as active symptoms do not commonly develop, in 
infants and young children, until long enough after the exposure to the 
contagion for them to fail to see and recognize the connection between 
the exposure and the subsequent development of tuberculosis. If active 
tuberculosis followed as quickly upon exposure to the contagion as do 
diphtheria and scarlet fever, the laity would then quickly recognize the 
fact and insist upon such measures of isolation, quarantine and disinfec- 
tion as would greatly reduce the prevalence of this disease. 

Tuberculosis is very rarely contracted in utero by direct transmission 
through a tuberculous placenta; about forty such cases have been reported. 
It is not proven, however, that this disease can be transmitted by tuber- 
culosis of the spermatozoa of the male or the ovum of the female without 
the intervention of a tuberculous placenta. 

Heredity. — Heredity has from the earliest times been believed to be 
a most important factor in producing tuberculosis. At present, however, 
in the sense that one means that the patient has inherited a specific sus- 
ceptibility to tuberculosis, heredity is believed to be a very unimportant 
predisposing factor, that is to say the special tuberculous diathesis which 
was supposed to furnish a favorable soil for the tubercle bacillus, while not 
wholly a negligible, is a comparatively unimportant factor in its spread. 
The hereditary factor is not so much a specific tendency to this disease 
as it is a weak constitution which belongs to the puny offsprings of weak 
and tuberculous parentage. Children of this class are usually anemic, 
malnourished and unable to offer the normal resistance to the tubercle 
bacillus. The question therefore of family tuberculosis is largely a matter 
of infection. Over 50 per cent, of all patients with this disease give a 
history of other cases in the family. All children inherit a defensive 
mechanism which enables them, under favorable conditions, to combat more 
or less successfully the contagion of tuberculosis. This defensive mechan- 
ism, which is very weak in infancy, becomes gradually stronger as the 
child grows older. It may be weakened by inheritance or by disease. 

Acute Infectious Diseases. — Acute infectious diseases, especially 
those which involve mucous membranes and produce lymph-node enlarge- 
ment, such as measles, whooping-cough, influenza and enteritis, are very 
important predisposing factors in preparing the soil for tuberculous in- 
fection, and are also important in developing a latent into an active tuber- 
culosis. 

Poverty. — Tuberculosis is one of the greatest causes of poverty. Com- 
paratively prosperous families of the working class are, within a short 
period of time, reduced to abject poverty by reason of the fact that the 
productive member of the family is incapacitated from work by this dis- 
ease. This leads to bad hygienic surroundings, insufficient food, over- 
crowding and the rapid dissemination of tuberculosis among the other, 
and especially the younger, members of the family. Here the poverty 
caused by tuberculosis becomes a most important factor in its dissemina- 
tion. The winter season, by crowding poor families into dark and un- 



376 TUBEECULOSIS 

wholesome surroundings, deprives them of sunlight and fresh air and 
promotes the spread of this disease by diminishing the normal resistance 
of the child and increasing its opportunities for contagion. 

School Infection. — School infection is not as great a factor in 
spreading tuberculosis as it is in disseminating other contagious diseases. 
The protection here lies in the fact that a very great majority of the cases 
of tuberculosis in childhood are not characterized by active pulmonary 
symptoms, are not accompanied by the expectoration of tuberculous sputum, 
and are therefore not anything like so contagious as they are in adults, 
in whom the open pulmonary form is the common type of the disease. 

Age. — Age is the most important of all the predisposing factors. The 
great majority of the cases of tuberculosis are contracted in childhood, 
even though the active symptoms may not occur until much later in life. 
The normal adult is practically immune from this infection; the vast ma- 
jority of the cases of adult tuberculosis are the result of infection in child- 
hood. Infancy is the most susceptible of all ages and perhaps there is no 
such thing as immunity during this period of life. If the young infant 
is repeatedly exposed to the contagion it will almost surely contract the 
disease, and yet the first few months of life show comparatively few cases. 
This may perhaps be due to the facts that during this time the opportunities 
for infection are less, and the breast milk upon which most infants are fed 
confers a partial immunity. As the child grows older its power of re- 
sisting the tuberculous infection becomes greater, and the disease when 
contracted usually runs a much less virulent course. The increasing re- 
sistance of the tissues of the child to tuberculous processes does not result 
in less frequent infection, but it does result in localizing and diminishing 
the severity of tuberculous processes. The mortality returns do not give 
a correct idea of the prevalence of tuberculosis at different ages in children. 
In infancy the death rate is high, and represents a large percentage of all 
the cases occurring at this age; latent and chronic forms of the disease 
rarely occur in infants. In childhood the death rate, compared with the 
number of cases, is small; at this age most of the cases are chronic, and 
the disease may last for years. During childhood the prevalence of tuber- 
culosis gradually increases, and the severity of the disease gradually di- 
minishes ; the prevalence increases more rapidly and the severity diminishes 
more rapidly during the first three years of life than later. The frequency 
of tuberculosis in childhood has been a matter of much speculation since 
the mortality returns cannot be depended upon to determine the prevalence 
of this disease during this period of life. 

It is, however, generally admitted that at least 20 per cent, of all chil- 
dren living in cities have tuberculosis in a more or less active form. In 
many of these, however, the disease is running a very insidious course in 
the deep-seated lymphatic glands. Tuberculin skin reactions indicate that 
a much larger percentage carry tuberculous foci in a latent form; these 
cases may present absolutely no clinical symptoms. Examinations made at 
dispensary clinics and institutions for the care of children show that, among 



PATHOLOGY 377 

the children of the poor, from 60 to 80 or 90 per cent, react to the tuber- 
culin skin tests ; this determines the enormous prevalence of latent tubercu- 
losis in childhood. 1 In 1895 the author wrote as follows : "Concealed 
lymph- node tuberculosis is the characteristic tuberculosis of childhood and is 
more prevalent than all the chronic diseases of childhood taken together. 
It is all about us every day; in our asylums, our schools, and our homes, 
masquerading as a preturberculous condition, as anemia, neurasthenia, 
lithemia, malaria and other ill-defined conditions; but in the meantime it 
progresses apace, and too often only casts off its disguise after irreparable 
damage has been done." 

Pathology. — The tubercle bacilli find their way into the body through 
the portals of entry previously described, and in infancy and early child- 
hood usually find lodgment in the bronchial, cervical or mesenteric lym- 
phatic glands. Here they may be destroyed, or they may at once set up 
an active tuberculosis either at the point of entry or in some distant part 
of the body or, what is much more common, they may remain for months 
or years either dormant or in a slow state of incubation, until favorable 
conditions cause them to develop an active tuberculous inflammation. 

The initial and characteristic lesion produced by the tubercle bacillus 
is the miliary tubercle, which is a minute grayish, translucent, firm nodule, 
about the size of a millet seed, which can be rather readily seen with the 
naked eye. They are made up of epithelioid cells often arranged in con- 
centric layers, with occasional giant cells in their center; no vascular struc- 
tures have been observed in them ; tubercle bacilli are found in and among 
these cells. Under the influence of these bacilli, the tubercles multiply 
in number, become the center of active inflammatory changes, coalesce, and 
the oldest tubercles increase in size and commence to undergo a central 
necrosis which gradually transforms them into a cheesy mass. The spread 
of the tuberculous process may then occur by continuity and contiguity of 
tissues to neighboring parts, or by lymph and blood channels to more 
distant Organs, thus producing the various forms of tuberculosis in infancy 
and childhood. A short sketch of the individual pathological lesions of 
these various types of tuberculosis here follows: 

Lymph-Node Tuberculosis. — Lymph-node tuberculosis is by far the 
most common form in infancy and childhood. The initial lesion in the 
vast majority of instances not only begins in these glands but usually re- 
mains there for some time before the infection spreads to other tissues. 
The bronchial lymph nodes are of vastly greater importance as tuberculous 
foci because they are more frequently affected than any other lymph nodes 
in the body and because disease of these glands is of much more serious 
import in the spread of the disease to other and more vital tissues and 
because, by reason of their location in the bony cavity of the chest, their 
enlargement may produce severe pressure symptoms on the blood vessels, 
nerves and bronchi with which they are in close association. The bronchial 
lymph nodes, anatomically described as peritracheo-bronchial glands, are 

1 New Yorlc Medical Journal, August 10, 1895. 



378 TUBERCULOSIS 

divided into three groups. The first group, or tracheal glands, are situated 
on both sides of the trachea, beginning on the right side in the angle of 
the trachea and right bronchus; they ascend along the trachea to the sub- 
clavian vessels and, beginning at a corresponding point on the left side 
of the trachea, they ascend to the arch of the aorta and the recurrent 
laryngeal nerves. These glands are in relation with the arch of the aorta, 
the recurrent laryngeal and pneumogastric nerves, the pulmonary artery 
and the superior vena cava. The second group is situated in the angle 
formed by the bifurcation of the trachea and extends along the large 
bronchi. They are in relation with the large bronchi, especially on the 
right, and with the esophagus, aorta and pneumogastric nerve. The third 
group extends along the bronchi into the lungs; they are associated with 
groups of glands in the angles of the bifurcation of the large bronchi as 
far as the fourth bifurcation, and with the veins and arteries which ac- 
company the bronchi into the lungs. The anterior mediastinal lymph 
nodes are in relation with the right innominate artery, the right subclavian 
artery, and the arch of the aorta, and the posterior mediastinal lymph 
nodes are in relation with the esophagus and aorta. The cervical lymph 
nodes are very abundant and are in close association with the large ves- 
sels and nerves of the neck, but these nodes have little direct communication 
with the bronchial nodes, and their enlargement rarely produces pres- 
sure symptoms because they are not confined in a bony cavity. The 
superficial cervical lymph nodes below and behind the external ear and over 
the upper portion of the sternomastoid muscle, and the deeper cervical 
lymph nodes, in relation with the jugular veins, above and behind the 
clavicle, are commonly the site of tuberculous lesions. The mesenteric 
lymph nodes are very widely disseminated through the abdominal cavity 
and are in close association with the large nerves and blood vessels as well 
as with certain portions of the large intestine. A notable group is situated 
in the region of the appendix which is not uncommonly enlarged in mesen- 
teric tuberculosis and forms a readily palpable tumor. The mesenteric 
lymph nodes, being unconfined by bony walls, do not usually by their en- 
largement produce pressure symptoms on the blood vessels and nerves 
with which they are in contact. But these nodes, unlike the cervical ones, 
are in close communication through lymph channels with the bronchial 
nodes, so that a tuberculous infection of these glands commonly leads to 
a secondary infection of the bronchial glands. On the other hand, bron- 
chial lymph-node tuberculosis does not so commonly lead to infection of 
the mesenteric glands; this is perhaps explained by the direction of the 
lymph stream. 

The agglutination and caseation of tubercles, with the resulting in- 
flammatory changes, may cause great enlargement of lymph nodes and 
necrosis of lymphatic tissues. This destruction gradually involves neigh- 
boring nodes and the intima of adjacent lymph and blood vessels. In 
this manner masses varying in size from a pea to a hen's egg may be formed, 
producing mechanical as well as septic symptoms. An important fact in 



PATHOLOGY 



379 



the pathology of lymph-node tuberculosis is that, even after the deep-seated 
bronchial and mesenteric lymph nodes have undergone more or less casea- 
tion, nature, as a rule, succeeds in encapsulating, absorbing, and calcifying 
them, thus preventing further infection by the discharge of tuberculous 
pus through ulceration into the blood vessels, the bronchi, the trachea, the 
esophagus, the pleura, the pericardium, the peritoneum, or the surround- 
ing cellular tissues. While all of these may occur they are comparatively 
uncommon, and recovery without ulceration after caseation of deep-seated 
lymph nodes is the rule rather than the exception; but caseation of ex- 



Thyroid gland' 

Gl.submaxill.. 
Trachea 
Asc. aorti 
Gl. track. -cesophag, 
Gl. subclavical, 

Gl. mediast. ant 

Vena cava suDerior, 

Gl. trach.-bronch. — * 

Gl. pulmonales. 

Bronchi 

Gl. pleuropulmon. 

Thoracic duct. 

Lung 



Gl. auric, ant. 

Gl. auric, post. 

Gl. jugul. sup. 

Gl. cervic. superfic. (fore part) 
Left subclavian vein 
Gl. supraclavicular es 




Left lymphatic trunk 
Gl. axill. 

Left main bronchus 
Gl. between great 
Desc. aorta vessels 

Gl. pleuro costales caVdmm' 

Pericardium 

(Esophagus 
Gl. lymph, sterni 
Diaphragm 



Fig. 61. — Bronchial and Other Lymph Nodes Mainly Affected in Tuberculosis. 

(Pfaundler and Schlossmann.) 



ternal lymphatics in the neck, the groin, the axilla and elsewhere is more 
commonly followed by ulceration and the discharge of pus externally. 

Pulmonary and Pleural Tuberculosis. — The lungs and pleura are 
not usually the site of the primary lesion in the tuberculosis of infants 
and young children; these organs are, however, as a rule, involved second- 
arily in all forms of severe tuberculosis. The lungs especially are almost 
always involved in well-advanced tuberculosis, and in the later stages 
of this disease are commonly the site of widespread and destructive lesions. 
These lesions follow mainly two general types, a widespread dissemina- 
tion throughout the lungs and pleura of gray miliary tubercles accompanied 



380 TUBEECULOSIS 

by an intense congestion and hyperemia of the involved parts ; or localized 
patches of yellow, caseating tubercles which coalesce, break down, and dis- 
charge their purulent contents into the bronchi or, more rarely, into the 
pleura, thus forming small cavities scattered throughout the lungs. If 
the pulmonary process is a chronic one more or less fibrosis may occur 
around the diseased areas, resulting in encapsulation, absorption and cica- 
tricial contraction. Tuberculosis of the pleura, which is usually associated 
with pulmonary tuberculosis, produces thickening of that membrane and 
fibrous adhesions which may interfere with pulmonary expansion. Em- 
pyema may occur. The most marked differences between the pulmonary 
lesions of infantile and adult tuberculosis are as follows: Infantile pul- 
monary tuberculosis is more disseminated; begins in the middle and lower 
lobes rather than in the apex; is commonly secondary to tuberculosis of 




Fig. 62. — Enlarged Bronchial Glands at Right Hilum. (S. Lange.) 



the bronchial lymph nodes, and is always accompanied by an active tuber- 
culosis of these glands. 

Intestinal Tuberculosis. — Intestinal tuberculosis may be secondary 
to mesenteric lymph-node tuberculosis, or it may be primary, due to the 
swallowing of tubercle bacilli. Primary intestinal tuberculosis is a rare 
lesion, according to Bovaird, who, combining his own cases with those of 
Holt and Northrup, found only five primary intestinal cases out of a 
total of 369 cases upon whom careful autopsies had been made. Intestinal 
lesions usually begin with the formation of miliary tubercles in Peyer's 
patches; they multiply, coalesce, break down, and produce ulcers; these 
ulcers may gradually increase in size until they run together, forming 
long, ulcerated patches lying opposite to the mesenteric attachment; in 
healing they may cicatrize, causing more or less contraction of the intes- 
tine in its long axis. 



PATHOLOGY 381 

Tuberculous Peritonitis. — Tuberculous peritonitis is secondary to 
intestinal or peritoneal lymph-node tuberculosis; the three conditions are 
very commonly associated. In peritonitis the peritoneal membrane is 
studded with tubercles, which set up a more or less active inflammation 
that may result in an exudation of fibrin, binding together the intestinal 
coils, the omentum and abdominal peritoneum, so that the whole peritoneal 
cavity may be obliterated; in other instances the exudation may be sero- 
fibrinous, resulting in a certain amount of agglutination of the intestinal 
coils, with a greater or less quantity of serum in the peritoneal cavity, 
thus producing ascites; or the tubercles may adhere, forming large masses 
which disintegrate, producing pockets of pus; these may ulcerate and 
discharge their contents through the abdominal wall or into the intestine. 
The writer once observed a case of this kind which ulcerated through the 
intestine and also through the umbilicus, forming a fecal fistula, which 
persisted for a number of months until the child's death. 

General Miliary Tuberculosis. — General miliary tuberculosis is 
caused by the discharge of tuberculous pus into the blood or lymph streams. 
The tubercle bacilli are thus widely distributed throughout the body and 
find a lodgment in various organs, especially the lungs, liver, spleen, kid- 
neys and brain. Miliary tubercles are soon widely disseminated through 
these organs and later every organ in the body may be involved. Around 
these tubercles is a small congested inflammatory area, especially marked 
in the lungs. The liver and spleen are enlarged. 

Bone and Joint Tuberculosis. — Bone and joint tuberculosis is sec- 
ondary to tuberculous foci elsewhere, and the contagion is carried by the 
blood and lymph channels to these structures. This manifestation of tu- 
berculosis in the vast majority of cases begins in childhood, and is one 
of the common manifestations of this disease. The bones most frequently 
affected are the vertebrae, the short bones of the hands and feet and the 
epiphyseal portions of the long bones. Botch's table of 3,820 cases shows 
the relative frequency with which the various joints of the body are at- 
tacked. 

Botch's Table from the Children's Hospital, Boston. 

Spine 1964 

Hip 1402 

Ankle 300 

Knee 104 

Wrist 20 

Shoulder 15 

Elbow 15 

This form of the disease begins by a deposit of tubercles in the can- 
cellous tissue of the bone near the joint, and there result a grayish-red 
infiltration and inflammation which may be followed by caseation with the 
destruction of bony tissue and perforation into the joint, producing a 
purulent synovitis. The joint surfaces are usually involved before casea- 
tion of the bone takes place, and there are produced a sero-fibrinous exuda- 



382 TUBERCULOSIS 

tion into the joint cavity and a deposit of tuberculous granulation tissue on 
the synovial membrane ; this granulation tissue may caseate and thus form 
a purulent synovitis. It is important, however, to remember that both 
bone and joint tuberculosis in their earlier stages commonly yield to 
rational medical and surgical treatment. 

Symptomatology. — In studying the symptomatology of tuberculosis the 
following clinical types of this disease will be considered in the order 
named : 

Tuberculosis of lymph nodes. 

General miliary tuberculosis in infants. 

General miliary tuberculosis in older children. 

Tuberculous bronchopneumonia in young children. 

Tuberculosis of lungs in older children. 

Tuberculous peritonitis. 

Tuberculosis of bones and joints. 

(Tuberculous meningitis is studied with the other forms of meningitis.) 

Lymph-Node Tuberculosa. — 1 This form of tuberculosis, when it in- 
volves other than the cervical lymph nodes, is so obscure and so commonly 
overlooked that it is of the utmost importance that the physician should 
always keep in mind its prevalence and be constantly on the lookout for 
its signs and symptoms. Many years ago I expressed the opinion, now gen- 
erally concurred in, that pronounced simple anemia, occurring in young 
children with a history of exposure to tuberculous contagion, was strongly 
suggestive of concealed lymph-node tuberculosis, and upon these condi- 
tions alone one was warranted in making a tentative diagnosis of tu- 
berculosis and putting the child upon the treatment for this disease. The 
type of anemia which occurs in tuberculosis is a simple secondary anemia 
of the chlorotic type. 

Neurotic disease in children is very frequently an indication of con- 
cealed lymph-node tuberculosis. Over 34 per cent, of the last 400 tuber- 
culous patients taken from my dispensary records show well-marked neu- 
rotic disease, such as chorea, incontinence of urine, hysteria, general nerv- 
ous irritability and night terrors. A well-marked neurosis therefore oc- 
curring in a child without apparent cause should lead the physician to 
search for other symptoms of tuberculosis. Tuberculous children of this 
type are commonly precocious. The precocity, however, which is associated 
with concealed tuberculosis, is fitful and cannot be long sustained. In 
the beginning of the school year these children may make a brilliant 
showing, but they usually break down in the latter half of the year with 
well-marked neurotic disease associated with anemia and general physical 
weakness. In my dispensary records 45 per cent, of all neurotic children 
are actively tuberculous. 

Dyspnea and pain in the side are in my experience frequently as- 
sociated with bronchial lymph-node tuberculosis, even before there is any 
clear evidence of pulmonary tuberculosis. These symptoms are aggravated 

l New York Medical Journal, August 10, 1895. 



SYMPTOMATOLOGY 383 

by exercise, and, like the anemia and nervous symptoms, are of much 
greater significance when they occur in children with a tuberculous family 
history. 

Eespiratory Symptoms. — Tuberculous children catch cold readily and 
often suffer from frequent attacks of snuffles and nasal catarrh. The nasal 
discharge may be irritating and produce a slight eczema and thickening of 
the lip, giving a more or less characteristic expression. They may also 
suffer from frequent attacks of bronchitis even before an active pulmonary 
tuberculosis can be demonstrated. 

Abnormal dwarfishness may be an evidence of concealed tuberculosis. 
By an abnormal dwarf is meant not only one that is underweight, but 
one that also lacks symmetry in development. The relation of weight and 
girth of chest is of special importance in this particular. A marked dis- 
proportion between the weight and height, when associated with poor chest 
development and a family history of tuberculosis, should prompt a careful 
search for other signs of bronchial lymph-node tuberculosis. 

Progressive failure of health, loss of weight, or even failure to gain 
in weight, which in the growing child is equivalent to loss of weight in 
the adult, is frequently a symptom of lymph-node tuberculosis, and when 
these conditions exist without apparent cause tuberculosis should be sus- 
pected. 

The early appearance of and irregularity in the menstrual function 
commonly occurs in young girls suffering from lymph-node tuberculosis. 
Of 52 girls who were irregular in their menstrual function, 47 gave family 
histories of tuberculosis and 5 gave family histories free from tuberculosis. 
Of 110 girls who were regular in their menstrual function, 80 gave non- 
tuberculous family histories, and 30 gave family histories of tuberculosis. 
A family history of tuberculosis implies also the more important fact 
that there was exposure to the tuberculous contagion. 

If the mesenteric lymph nodes be tuberculous, and they are rarely 
involved independently of the bronchial lymph nodes, we may have, to a 
greater or less degree, associated with the above symptoms dyspepsia with 
a tendency to chronic diarrhea. Obstinate diarrhea and other gastrointes- 
tinal disturbances may occur in this variety of tuberculosis even before le- 
sions appear in the intestinal mucosa; enlargement of the spleen is com- 
monly associated with these symptoms. 

Fever may or may not be present in lymph-node tuberculosis, but where 
the disease is at all active a slight rise of the temperature may usually be 
discovered, and in aggravated cases it may rise regularly to 103° or 104° 
F. some time during the day. The temperature in these cases produces 
little or no discomfort, so that it is not unusual for a child with a tem- 
perature of 103° F. to protest that there is nothing the matter with it. 
Night sweats may be present, even though there be but a slight rise of 
temperature. They are associated with the anemia, nervousness and mal- 
nutrition of lymph-node tuberculosis. 

Friedlander has called attention to the fact that a relative and ab- 
26 



384 TUBEKCULOSIS 

solute lymphocytosis occurs in lymph-node tuberculosis, and when this 
fact is taken in connection with the well-established fact that certain 
other diseases, such as whooping-cough, also produce lymph-node enlarge- 
ment, and are accompanied by a lymphocytosis, he suggests that this 
sign may be a valuable one in testifying to the existence of an inflamma- 
tion of the lymph glands in cases where concealed tuberculosis is suspected. 

Enlargement of external lymph nodes in the groin, axilla, neck and 
elsewhere may be a very important sign of the existence of bronchial or 
mesenteric lymph-node tuberculosis. The presence of enlarged external 
lymph nodes, which can be easily seen and felt, if associated with the 
symptom group previously described, is of the greatest value in confirming 
the diagnosis of concealed tuberculosis, but it must be remembered that 
a very advanced stage of bronchial lymph-node tuberculosis may exist with 
little or no enlargement of external lymphatics, and it must also be 
remembered that a very extensive lymph-node tuberculosis may occur in 
the cervical and other superficial lymphatics with little or no involvement 
of the deep-seated bronchial or mesenteric lymph nodes. The extent of 
the disease, therefore, in external lymphatics bears absolutely no rela- 
tionship to the extent of the disease in deep-seated lymphatics. 

Shin tuberculides, described by Hamburger, may appear as small, red 
or brownish papules, perhaps three or four in number, scattered over the 
body. They soon become covered with a small crust, which on removal 
leaves a depression. In this crust tubercle bacilli may be found. 

Physical signs are rather unreliable because of their variability. Great 
enlargement of the bronchial lymph nodes may exist without producing 
physical signs which will lead to their detection, but in some cases the 
physical signs are of importance. Percussion may elicit dullness over 
and on either side of the manubrium sterni, and on either side of the 
spine in the interscapular region ; the dullness is more frequently found 
on the right side. Auscultation is even less reliable than percussion. 
Grancher believes that the harsh breathing sounds, which are normal in 
the right apex of the child, when greatly exaggerated, are a sign of im- 
portance. The bronchovesicular breathing, with prolonged and harsh in- 
spiration, which may be heard in some instances at the apex, is especially 
important if it occurs on the left side. Feeble breath sounds over the 
whole of one lobe are a sign of significance. A venous hum, as noted by 
Eustace Smith, may sometimes be heard over the manubrium if the 
head of the child is bent backward so that the enlarged gland will com- 
press the left innominate vein against the sternum. 

Palpation in mesenteric lymph-node tuberculosis is of great value, 
since an enlarged spleen may usually be found and deep-seated lymph 
glands, especially in the region of the appendix, may be made out. In 
bronchial lymph-node tuberculosis, however, palpation is of little value, 
since these glands cannot be felt. Deep palpation, however, in the epi- 
sternal notch beneath the clavicle, may reveal enlarged glands, which may 
be associated with the bronchial chain. 



PLATE IV. 






The von Pirquet Tuberculin Skin Reactions. 
(From Hamill, Carpenter and Cope). 



DIAGNOSIS 385 

Pressure signs produced by enlarged lymph nodes are at times a signal 
aid in confirming the diagnosis of bronchial lymph-node tuberculosis. 
Hall, in a comprehensive review of the literature of this subject, has 
called special attention to the value of these signs. A severe paroxysmal 
cough, resembling pertussis, occurring more frequently at night, and 
often associated with asthmatic breathing, is a common and very significant 
symptom. Pressure on the trachea may produce tracheitis, inspiratory 
dyspnea and cyanosis. Pressure on one bronchus, most commonly the 
right, may produce bronchitis and a diminished expansion, and feeble 
vesicular breathing over that portion of the lung to which the bronchus 
leads. Pressure on the esojmagus may produce difficulty in deglutition. 
Compression of blood vessels produces venous-stasis with edema of the 
face and arms, and pressure on the pulmonary veins may produce con- 
gestion of the lungs. Pressure on the recurrent laryngeal nerve may 
produce a hoarse, harsh cough and even aphonia. 

Radiographic examination of the chest may reveal the existence of 
enlarged bronchial lymph nodes and may be of value in confirming the 
diagnosis. If the lung be involved patches of consolidation and limita- 
tion of motion at base of diseased lung may be seen. 

Tuberculin reactions in recent years have come to be considered of 
great value in confirming the diagnosis of concealed tuberculosis. They 
are so sensitive that they reveal minute foci of tuberculosis in the latent 
or inactive forms of this condition. The presence of these reactions 
therefore does not always mean an active tuberculosis. The severity, 
however, of the reaction and the rapidity with which it occurs may be 
of some value in determining the degree of activity of the tuberculous 
process. This rule also has its limitations, since these reactions fail 
to appear in advanced cases, and their value lies not in making a dif- 
ferential diagnosis in the acute and grave forms of tuberculosis, but in 
determining the presence of tuberculous foci in suspected cases of chronic 
concealed tuberculosis. In these the reaction rarely fails, and a negative 
result would mean the absence of tuberculosis. Of these tuberculin re- 
actions, the Moro ointment test is the simplest of application and is 
sensitive enough for all practical purposes. The von Pirquet scarification 
test is also simple in its technique and more sensitive in its reaction. 
The conjunctival test is now rarely used, because it involves slight danger 
to the eye. The subcutaneous test presents no advantages over the others, 
is more complicated, and offers greater opportunities for infection. The 
technique of these tests is elsewhere given. 

Diagnosis. — From the foregoing outline it is evident that the diagnosis 
of concealed lymph-node tuberculosis is not only possible, but that the 
failure to make this diagnosis rather early in the disease indicates a lack 
of diagnostic skill and knowledge on the part of the attending physician. 
If the fact is kept in mind that it is the most common of all the chronic 
diseases of childhood, and that a history of possible exposure to the tu- 
berculous contagion may have occurred months and even years before the 



386 TUBERCULOSIS 

active symptoms are developed, the physician will then be prepared to 
interpret the syndrome above outlined. Anemia, neurotic disease, gen- 
eral malnutrition, dyspnea and pain in the side on exercising, proneness 
to catch cold, frequent attacks of bronchitis, abnormal dwarfishness, pro- 
gressive failure of health, loss of weight, chronic diarrhea with enlarge- 
ment of the spleen, slight intermittent fever, lymphocytosis, enlargement 
of external lymph nodes, or paroxysmal cough resembling pertussis, oc- 
curring in a child between the ages of two and fifteen, should lead to a 
tentative diagnosis of concealed lymph-node tuberculosis, which may be 
confirmed or disproven by a careful physical examination, the subsequent 
history of the case, and, if necessary, by tuberculin skin reactions and 
radiographs. 

Tuberculous Cervical Adenitis (Scrofula). — Tuberculous cervical 
adenitis is almost as common as tuberculous bronchial adenitis; the two 
conditions, however, present altogether distinct symptom groups. The cer- 
vical lymph nodes are not in close anatomical connection with the bron- 
chial glands. The clinical facts that bronchial adenitis is very common 
and cervical adenitis very rare in infancy, and that cervical adenitis in 
the older child often occurs without evidence of bronchial adenitis, con- 
firm the belief that there is little direct communication between these 
two groups of glands. The clinical picture of cervical adenitis may be 
quite independent of bronchial adenitis, and the existence of the two 
symptom groups in the same child means, in the majority of instances, 
that the child has an independent infection of the two groups of glands 
rather than that the infection has traveled from one group to the other. 
Tuberculous cervical adenitis is essentially a disease of childhood; it is 
comparatively rare in the infant and adult. The great majority of the 
cases occur between the third and fifteenth year of life. 

The diagnosis of cervical adenitis is a very simple matter. The lymph 
nodes involved are readily palpable and the only question which may arise 
is as to whether their enlargement is due to an inflammation produced by 
tubercle bacilli or other microorganisms. In tuberculous cervical aden- 
itis the process is essentially a chronic one and the glands are less tender. 
When suppuration occurs through the skin the reparative processes are 
slower and there is more tendency to sinus formation and to scar tissue. 
There are also very frequently blepharitis, phlyctenular keratitis, coryza, 
chronic nasal catarrh and eczema of the lip and face. A positive diagnosis 
of the character of the microorganism producing the adenitis cannot 
always be made without dissecting out the gland (which is the best treat- 
ment in troublesome cases), and subjecting it to a microscopical examina- 
tion or injecting it into a guinea-pig. Because of the fact that the great 
majority of the chronic cases are tuberculous and because of the im- 
portance of instituting proper treatment in these cases, it is wise for the 
physician to treat all such cases as tuberculous. When the disease is 
confined to the cervical glands the constitutional symptoms are not marked ; 
if pronounced anemia and severe malnutrition are present the inference 



DIAGNOSIS 387 

is that the bronchial or other deep-seated lymph nodes are involved. Tu- 
berculous cervical adenitis usually manifests itself by enlarged glands in the 
sub-maxillary region, varying in size from a hazelnut to a walnut; these 
may coalesce and form large, solid tumor masses. Suppuration may occur, 
with the discharge through the skin of curdy, cheesy pus, forming a sinus 
which remains open or is only temporarily closed, until the whole of the 
glandular tissue involved is disintegrated and discharged. Following and 
accompanying this process the skin may be marked by large, rough, un- 
sightly scars. Cervical adenitis may be aggravated, or even caused by 
disease of the adenoids, tonsils and pharynx. 

General Miliary Tuberculosis in Infants. — This is a very in- 
sidious disease, presenting, as a rule, only the symptoms of general mar- 
asmus. The infant commences to lose in weight and strength, and is 
anemic. A slow wasting and failure in health, without apparent cause, 
is the dominant symptom. This condition is commonly mistaken for some 
disease on the part of the gastrointestinal canal. The infant, as a rule, 
takes but little food and has secondary digestive disturbances, such as 
regurgitation of food, vomiting and diarrhea, and the stools may show 
lack of digestion and assimilation. After a longer or shorter time, usually 
some months, there is fever, which may be constant or intermittent, the 
spleen and liver are enlarged, the digestive disturbances are increased and 
the lungs commence to show evidence of bronchitis and then broncho- 
pneumonia. The terminal symptoms are continuous fever, more or less 
cough, rapid pulse and great prostration. Death may result from gen- 
eral exhaustion, resembling marasmus, from a terminal bronchopneumonia 
or tuberculous meningitis. 

General Miliary Tuberculosis in Children Over Five Years of 
Age. — This disease is always secondary to tuberculous foci elsewhere in 
the body, which have ulcerated into the blood or lymph streams and pro- 
duced the general infection. These previous foci may be located in the 
lungs or the bones, but in the vast majority of instances they are in the 
lymph nodes, and this is the reason why this form of tuberculosis is nearly 
always preceded by the symptoms of lymph-node tuberculosis. This fact 
cannot be too strongly insisted upon. Following the symptoms of lymph- 
node tuberculosis previously given, the child becomes acutely ill with a 
continuous fever, marked by general prostration and progressive emaciation, 
causing a clinical picture closely resembling that of typhoid fever in the 
adult. The two conditions, however, should not be confused. In general 
miliary tuberculosis the fever, although continuous, is not as regular as 
that of typhoid, the spleen is not so frequently enlarged, digestive dis- 
turbances are not, as a rule, marked, rose spots are absent, the Widal re- 
action is negative, and as the disease progresses the fever does not abate 
at the end of the third or fourth week, but continues with increasing pros- 
tration, emaciation, and cachexia. A tuberculous bronchopneumonia or 
meningitis may terminate the clinical picture. 

Tuberculous Bronchopneumonia. — This condition occurs most com- 



388 TUBEECULOSIS 

monly in young children between the ages of two and five. It may be 
the terminal picture of the marantic type of general miliary tuberculosis 
in the infant. In the child it is much more commonly the sequel of a 
bronchial lymph-node tuberculosis which has existed for months or even 
years and has been finally developed into a tuberculous bronchopneumonia 
by an attack of measles, whooping-cough, influenza, or bronchitis. The 
temperature chart (page 460) indicates the course the fever may take 
and also the increase in respiration as the disease progresses. Cough, 
dyspnea, cyanosis and great prostration are present. Tubercle bacilli can 
usually be demonstrated in the sputum, which is caught by wiping out the 
pharynx with a piece of gauze during an attack of coughing. The disease 
in younger children may run from two to four weeks and is almost in- 
variably fatal. In children from four to six years of age it may last six 
or eight weeks, with great variations in the severity of the symptom 
group. The apparent improvement which so often occurs in these cases 
is very misleading, since an acute exacerbation of the symptoms, as a rule, 
quickly follows, and the disease progresses to a fatal termination. In 
some instances, however, especially in older children, one of these in- 
tervals of apparent convalescence may be prolonged into an actual con- 
valescence, and the child is again slowly restored to health. 

The physical signs are those of acute bronchopneumonia elsewhere 
described. Bales of various kinds may be heard over the lungs. Over 
small areas crepitant rales, diminished resonance and broncho-vesicular 
breathing may be found. The physical signs, however, may occur late and 
are often very elusive. The diagnosis is therefore commonly made by the 
tuberculous family history; previous or present symptoms of tuberculosis 
elsewhere in the body; the onset of the disease after one of the acute 
infections; the presence of tubercle bacilli in the sputum, and the symp- 
toms and signs of an acute bronchopneumonia, running, especially in 
slightly older children, an irregular and prolonged course. 

Tuberculosis of Lungs in Older Children. — Pulmonary tubercu- 
losis, in children between the ages of six and fifteen, is usually preceded 
by and almost always associated with bronchial lymph-node tuberculosis. 
The symptomatology, therefore, of the two conditions is inseparably as- 
sociated. In the great majority of instances there is a longer or shorter 
interval of time in which the symptoms of bronchial lymph-node tuberculo- 
sis are present before the pulmonary symptoms can be noted. In other in- 
stances the infection of the lung and the lymph nodes may be almost coin- 
cident, and in these cases the two symptom groups may be combined from 
the beginning of the disease. The pulmonary disease, extending, as it com- 
monly does, from the bronchial lymph nodes, involves the middle portions 
of the lungs, extending first to the upper lobes and after a time involving 
the lower lobes. 

The symptoms are those of bronchial lymph-node tuberculosis, asso- 
ciated with recurring attacks of tuberculous bronchitis, or bronchopneu- 
monia. After a time the tuberculous process localizes itself more definitely 



DIAGNOSIS 



389 



in the lungs, and then takes the form and presents the symptoms and phys- 
ical signs of phthisis in the adult. The resistance to the progress of 
this disease is not, however, as great in the child as it is in the adult, and 
it therefore runs a more rapid course and has a more unfavorable prog- 



nosis. 



The diagnosis in these cases is made by the family history, the pre- 
ceding or accompanying symptoms of bronchial lymph-node tuberculosis, 




Fig. 63.- 



-PULMONARY TUBERCULOSIS WITH LEFT-SIDED PNEUMOTHORAX. 

(S. Lange.) 



the recurring attacks without apparent cause of bronchitis and broncho- 
pneumonia, and later the physical signs of phthisis, and, most important 
of all, the finding of tubercle bacilli in the sputum. The sputum may be 
obtained by irritating the epiglottis, thus producing a cough, and as the 
mucus is brought up it is caught in the back part of the throat on a 
piece of gauze. This method of obtaining mucus is, as Holt has demon- 
strated, very successful; tubercle bacilli may be found in the mucus thus 
obtained in at least 70 or 80 per cent, of the cases of pulmonary tuber- 
culosis in children. 



390 



TUBERCULOSIS 



Tuberculous Peritonitis. — Tuberculous peritonitis occurs most 
commonly between the fifth and the tenth year of life, and is usually 
secondary to mesenteric lymph-node tuberculosis; but it may also occur 
in the later stages of other forms of tuberculosis, especially the general 
miliary tuberculosis of infancy. The onset of this condition is commonly 
preceded, for a considerable period of time, by the symptoms of lymph- 
node tuberculosis. The characteristic symptoms of peritonitis are then 
slowly developed. There is abdominal tenderness with attacks of pain, 
vomiting, and constipation or diarrhea. The liver and spleen are usually 
enlarged. Abdominal distention, with resistance and induration 



are 



NOOE IN FRONT 

Of SACRAL , 

PROMONTORY 1\1 




COMMON ILIAC 
EXTERNAL ILIAC 



OBTURATOR 
NERVE 
OBTURATOR 
ARTERY 



OBTURATOR 
NODE 



Fig. 64. — Iliopelvic Lymph Nodes. (Poirier and Charpy.) 

marked, and these signs may be more or less localized, especially in the 
early stages. Increase in the abdominal distention, with or without ascites, 
may occur. Tumor masses may be felt, especially in the right iliac re- 
gion, about the head of the colon, and in the hypogastric region along the 
thickened omentum. Localized indurations may sometimes be demon- 
strated by rectal examination. As the process extends the abdominal in- 
duration becomes general, the abdominal distention more marked, and the 
emaciation of the arms, legs, face, and body more extreme. This phase of 
the disease may last for months or years with marked remissions and 
exacerbations in the symptom group, until death or a slow convalescence 
terminates the clinical picture. The fever of tuberculous peritonitis is 



DIAGNOSIS 



391 



irregular in type and the fluctuations in the temperature curve vary 
with the activity of the tuberculous process. For all practical purposes 
it is safe to assume that every chronic exudative peritonitis is tuberculous, 
notwithstanding the fact that Henoch and other German writers have 
described a very rare form of simple or non-tuberculous, chronic, exudative 
peritonitis occurring in older children. From a clinical standpoint it 
matters little whether such a disease exists or not. If it does, it is ad- 
mittedly a very rare affection and its treatment is the same as that of 
tuberculous peritonitis. 

While the above clinical picture is the most characteristic and the 
most common one presented by tuberculous peritonitis, sharp variations 
may occur, especially in acute cases. The sudden onset, presenting the 
symptoms of fever, vomiting, constipation, abdominal distention and ten- 
derness in the right iliac region, may closely resemble acute perforative 
appendicitis, and the differential diagnosis may depend upon the previous 
history or the findings of an exploratory incision. Less acute cases with 
fever, diarrhea, large spleen, abdominal distention, and right iliac tender- 
ness may present a picture somewhat like t} 7 phoid fever. In these cases 
the differential diagnosis may depend upon the absence of rose spots, a 
negative Widal reaction, and the subsequent course of the disease. 

Tuberculosis of Bones and Joints. — This is a common manifesta- 
tion of tuberculosis in children between the ages of three and fifteen. 
It presents itself in a num- 
ber of distinct clinical types, 
of which the most important 
are: Pott's disease, hip-joint 
and knee-joint disease and 
tuberculous dactylitis. All of 
these are surgical affections, 
but because of the importance 
of an early diagnosis their 
characteristic local manifest- 
ations are here briefly noted. 

Pott's disease (caries of 
the spine) is a chronic tuber- 
culous disease of the spine, 
characterized by the symp- 
toms of lymph-node tubercu- 
losis previously given, and by 
a localized stiffness, rigidity, 
pain, and tenderness in some 
portion of the spinal column. 
The pain is commonly referred to the parts supplied by the spinal nerves 
irritated by the diseased bone. During this stage the child assumes a 
position in walking and stooping which will relieve pressure on the verte- 
brae and keep the spinal column rigid. Later the spinal curvature, which 




ANTERIOR 
|_CeCAL 
NODES 



Fig 



-Lymphatics of the Cecum and Appen- 
dix. (Poirier and Charpy.) 



392 



TUBEKCULOSIS 



determines the diagnosis, makes its appearance. This is usually a sharp 
posterior curvature producing a characteristic deformity. It may be dif- 
ferentiated from rachitic and other spinal curvatures by its immobility, 
as demonstrated in the chapter on Examination of the Sick Child. Com- 
pression myelitis may result when the disease is in the upper half of the 
spine. If the cervical vertebrae be affected, the neck is held stiff, motion of 
the head produces pain, usually of a neuralgic type, involving the occipital 
region and sides of the neck. If the dorsal vertebrae be involved, the body 
of the child is held rigid and intercostal neuralgia and abdominal pains are 
complained of. If the lumbar spine is diseased the neuralgic pain extends 
into the legs and may be located in the hip or knee. 

Hip-joint disease is a chronic tuberculous disease of this joint which, 
as a rule, is very insidious in its onset. It is, however, usually preceded 

and accompanied by the symp- 
toms of lymph-node tuberculo- 
sis previously described. Lame- 
ness, sharp paroxysmal pain 
often referred to the knee, ten- 
derness of the joint and disin- 
clination to walk mark the 
onset, Tenderness may be elic- 
ited by pressing the joint sur- 
faces together, and as this in- 
creases the lameness becomes 
more marked. Keflex muscu- 
lar rigidity produces a stiffness 
of the joint or a limitation of 
its motions. The muscles of 
the thigh and calf show marked 
atrophy, and if the child is 
placed in an upright position 
the flattening in the gluteal 
fold of the affected hip and 
lack of symmetry of the two 
sides are very characteristic. 
As the disease progresses to 
the second stage the hip joint 
becomes fixed, the thigh flexed 
and somewhat adducted, due to contraction of the ilio-psoas muscle from 
muscular spasm. The cordlike contracture of this muscle is an important 
diagnostic sign. Lordosis and tilting of the pelvis occur. In the third 
stage the thigh is rotated inward, adducted, and the deformity of the hip 
becomes much greater. The leg is drawn up by muscular action, is several 
inches shorter than normal, and, while the hip may be much swollen, the 
lower portion of the thigh and leg are wasted. An abscess may form and 
r ( )oint in Scarpa's triangle in the gluteal region or above Poupart's ligament. 




Fig. 66. — Tuberculosis of Spine. 
disease.) 



(Pott's 



PROPHYLAXIS 393 

Knee-joint tuberculosis is characterized by pain and a chronic "white 
swelling" of the joint. The joint motions are limited and the swelling is 
commonly boggy or gelatinous in character. 

Tuberculous dactylitis occurs in the phalanges of the hands and feet. 
The swelling extends from joint to joint, is essentially chronic, is pyriform 
in shape and boggy in character. 

An X-ray picture may be of great value in confirming the diagnosis 
of bone and joint tuberculosis. 

Prophylaxis. — In April, 1896, I was asked to take charge of a tubercu- 
lous patient for the purpose of protecting her unborn child from tubercu- 
losis. On the mother's side there was a family history of tuberculosis. The 
father was sturdy and his family history had no tuberculous taint. The 
mother was confined to her bed with an advanced stage of pulmonary and 
laryngeal tuberculosis. 

The sick room, divested of all unnecessary hangings and carpets, 
was thoroughly cleansed; this was repeated at short intervals during the 
mother's long illness. A trained nurse was installed and instructed in 
the methods of destroying tubercle bacilli. The patient coughed into 
gauze napkins and the sputum was at once destroyed by fire. It was 
with the greatest difficulty that the mother was kept alive by hypodermic 
medication and such food and alcohol as she was able to take, until the 
baby was born in September, five months later. Previous to the birth of 
the child, a large and well-aired room on the same floor of the house as 
the mother's bedroom was selected. Everything was removed from this 
room, the paper was taken from the wall, the room repapered, the wood- 
work and floors scrubbed and washed down with a solution of bichlorid of 
mercury, and new furnishings supplied. On the birth of the child he 
was removed immediately to this room and placed in charge of a wet 
nurse. The mother lived nine weeks after the birth of her child and 
during this time, in deference to her self-sacrificing spirit, the infant 
was carried into the sick room once a day, remaining there for a few 
minutes only. But the mother, a very intelligent woman, did not nurse 
or fondle her child during this time. Before each daily visit of the infant 
to its mother's room, the windows of the sick room were opened and the 
room aired. On the death of the mother the whole house was carefully 
fumigated and cleansed. Every room was repapered, and the floors and 
woodwork scrubbed and washed down with bichlorid of mercury. The 
furniture was cleansed, the carpets and hangings all over the house were 
replaced by new ones and the bedding of the sick room was destroyed by 
fire. The infant, which at birth was very frail and malnourished, com- 
menced to thrive and gradually grew stronger, so that when he was a 
few weeks of age he commenced his daily outings. From that time lie 
was kept in the open air as much as possible, slept in a well-ventilated 
room and, when nine months of age, was gradually weaned and placed 
upon cow's milk. During the next five years of the child's life the fresh- 
air treatment was continued, and he was carefully fed within the range of 



394 TUBEKCULOSIS 

his digestive capacity; milk, eggs, meat, and cereals were utilized as 
much as possible in building up his nutrition; under this regime he con- 
tinued to thrive in a normal manner. During this period he was carefully 
protected from all contagious diseases, especially tuberculosis, measles, in- 
fluenza and pertussis. Between seven and nine years of age, however, he 
went safely through measles and pertussis, which he contracted at school. 
The boy is now seventeen years of age, is well developed physically, and is 
spending his winters in an Eastern boarding school and his summers in 
the open, camping out. At the time of the birth of this boy he had one 
sister, three and a half years of age, who lived in the same house and 
who was as carefully protected from tuberculosis during this time as was 
her younger brother. She is to-day a normal, sturdy girl of twenty. 

This narrative portrays the underlying principles which should be 
adopted in the prophylactic treatment of tuberculosis, and illustrates what 
can be accomplished by the careful carrying out of these principles, without 
removing the child from its immediate tuberculous surroundings. It also 
most forcibly illustrates the axiomatic fact that the prevention of con- 
tagion in family tuberculosis is largely a question of money. The father 
in this instance had ample means, was a ' man of intelligence, and urged 
that no expense be spared in the protection of his children, and the re- 
sult was a satisfactory one. 

The prevention of tuberculosis, however, among the poor is. altogether 
a different problem, and one that cannot be, or at least has not as yet been, 
satisfactorily solved. In dealing with an individual case the physician 
must therefore, within his limitations, carry out the following principles. 
Tubercle bacilli, from whatever source they may possibly come, must be 
destroyed by germicides or fire so as to prevent the contamination of the 
immediate surroundings of the patient. The sputum must be carefully 
collected and destroyed, and the room in which the tuberculous patient 
lives must be cleansed and disinfected as often as possible. Children 
should not be allowed to come in close contact with tuberculous individuals, 
as there is not only danger from the dried tubercle bacilli scattered about 
the /room, but also from the tuberculous spray which is projected, by 
coughing, several feet into the surrounding atmosphere. This rule ap- 
plies not only to the social and home life of the child, but also to its 
school life. Systematic school inspection is of importance in preventing 
the spread of tuberculosis and other infectious diseases. Kissing and 
fondling of children by tuberculous patients should be absolutely pro- 
hibited. Cow's milk should be obtained from a non-tuberculous herd of 
cattle, and its subsequent contamination by tubercle bacilli most carefully 
avoided, and where these conditions cannot be satisfactorily carried out 
the milk should be pasteurized for forty minutes at a temperature of 
140° F. 

An infant should under no conditions be allowed to nurse a tubercu-^ 
lous mother or wet-nurse, because such milk is not only likely to be in- 
nutritious, but because the child comes in such close contact with the 



TKEATMENT 395 

tuberculous nurse that there is great danger of its contracting the dis- 
ease. Under ordinary conditions it is far safer to separate the young 
child from its tuberculous surroundings for at least a portion of the 
time, in this way diminishing the danger of contagion and placing the 
child in surroundings where it can get purer air and more sunshine, look- 
ing to its physical upbuilding and increased resistance to the tuberculous 
contagion; where this cannot be done it is advisable to remove the in- 
fected member of the family and clean up the surroundings. 

Children with a tuberculous family history, which, as a rule, im- 
plies that they have had opportunities to contract the contagion, should 
be carefully guarded throughout their whole childhood from tuberculosis, 
measles, pertussis and influenza, the last three named diseases being 
especially potent factors in preparing the soil and opening the gateways 
for tuberculous contagion, and also in developing a latent into an active 
tuberculosis. Children of this class should, if possible, live in the 
country and spend their winters in some warm, dry climate, which will 
enable them to live an out-of-door life, but wherever they are located, in 
the city or in the country, under suitable or unsuitable climatic con- 
ditions, they should live in the open air and sleep in well-ventilated rooms, 
or out of doors, when possible. During all of this time they should have 
great care given them in the selection of their food. Eating good, nu- 
tritious food at proper intervals and indulging in outdoor sports will 
do much to develop a physique which gives the child an increased re- 
sistance to the tuberculous contagion. Because of the prevalence of tu- 
berculosis all children, whether coming from tuberculous stock or not, 
should, to protect them not only from this, but from other contagious 
diseases, have careful attention devoted to diseases of the nose, pharynx, 
tonsils and adenoids. The eradication of diseased tissues in these loca- 
tions will at least partially close the most common gateway, not only to 
tuberculosis, but to a number of other contagious diseases. 

Treatment. — General Treatment. — As previously noted, lymph-node 
tuberculosis is more common than all the other contagious diseases of 
childhood. The fact therefore that it is so prevalent and that it is so 
insidious should make the physician very quick to suspect its presence, 
and to institute proper treatment long before the serious types of this 
disease announce themselves in a form that places the child beyond the 
reach of curative treatment, and also before such diseases as measles, 
pertussis, influenza, and bronchopneumonia make the diagnosis by de- 
veloping a curative into a much more serious form of tuberculosis. The 
principles which underlie the successful treatment of active tuberculosis 
in children are very much the same as those above outlined under Prophy- 
lactic Treatment. The child, if of school age, must stop school and live 
an outdoor life in a moderately bracing climate that will give him the 
purest air, the most sunshine, and the most equable temperature. These 
axiomatic facts mean that the individual child, within the limitations of 
the circumstances surrounding it, should have as much country life as 



396 TUBEKCULOSIS 

possible either at home or in a more suitable climate. Southern Califor- 
nia and portions of South Carolina, Georgia, Florida, Texas, and New 
Mexico offer suitable winter climates, while the Adirondacks and Colorado 
offer satisfactory summer climates. The advantages of sanatoria in the 
treatment of tuberculosis in childhood are nothing like as great as they are 
in the adult. The sanatorium treatment in children would be of advantage 
to those who have not the means to take proper care of themselves at 
home or to take advantage of a change of climate when the conditions 
demand it; such sanatoria would have to be furnished by the state. The 
facilities for sanatorium treatment among the poor are very limited; the 
most that can be done for these children at the present time is to send 
them for short stays to "Fresh Air Farms," and other like excursions 
into the country. The tuberculosis dispensaries as now organized in 
large cities are of great value in the treatment and prevention of tu- 
berculosis among the poor. These dispensaries, with their doctors and 
visiting nurses, keep in touch with their patients and, by cooperation 
with "fresh air" and other organized charities, are able, in a limited way, 
to give them better air and better food. 

While the climatic treatment of tuberculous children is in selected 
cases of the greatest possible value, yet the fact remains that the vast 
majority of tuberculous children must be treated at home, if not for the 
whole, at least the greater portion of the year. It is encouraging therefore 
to note that the home treatment of tuberculous children among the well- 
to-do and middle classes is almost, or quite, as successful as any climatic 
or sanatorium treatment could be. The home offers many advantages, es- 
pecially in the way of proper food, quiet surroundings, well-ventilated or 
open-air sleeping apartments, and protection from other contagions. It 
may require that the family remove to the suburbs of the city in which 
they live and there give the child an out-door life with proper food and 
wholesome surroundings. The fresh-air treatment of tuberculosis is, as a 
rule, more satisfactorily carried out in the home than it is at a summer 
or winter resort to which the family have flown with inadequate means 
to provide for themselves and their sick child the proper sanitary sur- 
roundings. If the tuberculous process is active enough to produce fever, 
the home is by far the most satisfactory place for the treatment of such 
cases. These children require rest in bed for all or at least a greater 
portion of the day, and they must have what all tuberculous patients 
demand, fresh air, sunshine, and proper food. These conditions can best 
be complied with at home, except among the very poor, and they can 
be cared for in the fresh-air wards of our public hospitals. 

Fresh-air Treatment. — In properly carrying out this treatment the 
child should be required to sleep out of doors; this can be accomplished 
in the great majority of cases. My experience with the out-door treat- 
ment of tuberculosis, and many other diseases, has been in and around 
Cincinnati, Ohio; the winter climate here is like that of New York, 
Philadelphia and St. Louis, cold, damp, and unwholesome. From the 



TREATMENT 397 

latter part of December to the latter part of March the climate is most 
variable, rains, snows, high winds, zero temperature, and thawing weather 
may follow each other in rapid succession, and influenza, and catarrhal 
diseases prevail. Yet even in this climate very remarkable curative re- 
sults can be obtained from sleeping out of doors throughout the winter 
months. I have found that children, both sick and well, when they have 
once been trained to it, prefer porches and verandas to indoor sleeping 
apartments. During the extreme cold weather of winter, special sleeping 
garments and extra bed clothing are necessary, and the porch may be 
supplied with canvas drop curtains, one or more of which may be let 
down on stormy nights. Sleeping in rooms with wide open windows, 
while not as good, is a fair substitute for out-door sleeping apartments. 
The value of this fresh-air treatment for both sick and well children can 
scarcely be overestimated. After spending the best part of the day breath- 
ing the impure and germ-laden air of the schoolroom, it is a crime to shut 
children up in close and ill-ventilated sleeping apartments for the night. 
These are the conditions that aggravate tuberculosis and promote the 
spread of influenza and other contagions. Sleeping out of doors the year 
around is the most potent single measure we have for the cure of tu- 
berculosis, and it is much more effective in the chronic glandular tuber- 
culosis of childhood than it is at any other age or in any other form. 
In fact, this form of tuberculosis, between the ages of four and ten, yields 
almost specifically to the fresh-air treatment. 

Dietetic Treatment. — In children this is almost as important as the 
fresh-air treatment and can be carried out nowhere so well as at home. 
The nutritional problems of the tuberculous child must be carefully studied 
by the physician, and a diet containing food easily within the range of 
his digestive capacity should be carefully prescribed. Proper food at reg- 
ular intervals must be given over a long period of time. In the average 
child this food should be made up largely of milk, eggs, meat, and cereals, 
but the age and digestive capacity of the individual child must guide the 
physician in his selection of the diet. One fact should be firmly im- 
pressed upon the physician's mind, and that is that he can never cure a 
case of tuberculosis unless he is able to successfully solve the nutritional 
problems of the child. It is only the well-nourished child, with good 
digestion, continuously fed upon proper food, that finally gets well of 
tuberculosis. The younger the child the more important is the dietetic 
treatment and the less probable that a change of climate will be of 
greater curative value than careful dietetic home treatment. It is, of 
course, possible for the well-to-do to combine home life with change of 
climate. When this is possible we have the ideal conditions for the proper 
treatment of tuberculosis in children. It has not been my purpose here 
to undervalue the great curative power of a suitable climate in the 
cure of tuberculosis in children, but only to call attention to the fact that 
so much stress has been laid upon this factor that many children suffer- 
ing from tuberculosis are carried away from good homes to a boarding- 



398 TUBEKCTTLOSIS 

house or hotel life that does not offer as favorable opportunities for the 
treatment of this disease as they left behind them. The successful treat- 
ment of tuberculous children must for. the most part be carried out at 
home, and the climatic treatment is only a valuable adjunct, which is to 
be prescribed to meet the needs of the individual child. 

Best and Exercise. — Best and exercise should be as carefully pre- 
scribed to meet the needs of the patient as any of the other measures 
adopted for the cure of tuberculosis. All acute exacerbations of this 
disease, especially those associated with fever, loss of weight, and a weak 
and rapid pulse, should be treated by rest rather than exercise. Whether 
the child shall rest in bed, with wide-open windows, or on a lounge, or 
in a comfortable chair, will depend upon the severity of the acute symp- 
toms and upon its individual idiosyncrasies, the object being to give the 
child bodily rest without producing nervous irritability by the confine- 
ment which rest imposes. As it convalesces from acute symptoms, mod- 
erate exercise out of doors, under careful supervision, should be prescribed. 
In the more chronic forms of the disease, where the acute symptoms are 
in abeyance, more active exercise is of value. But at all times one should 
be careful to note that the prescribed exercise should not be of such a 
character or so long continued that it will produce undue fatigue or 
be followed by a rise of temperature. With these restrictions, out-of-door 
exercise is a most valuable adjunct in the treatment of tuberculosis in 
children. Swedish movements, general massage, mild gymnastics, and 
respiratory exercises are of value in individual cases, especially where there 
are poor chest development and general malnutrition, combined with rapid 
heart action and rise of temperature on moderate out-door exercise. 

Medical Treatment. — While fresh air and proper diet are recog- 
nized as the all-important measures in the treatment of tuberculosis in 
childhood, it is my belief that the administration of drugs is a very 
important adjunct to this treatment and that in recent years too little at- 
tention has been paid to this phase of the subject. In administering 
drugs, it is an axiomatic fact that all medicines which upset the di- 
gestion, interfere with the appetite, or disturb the normal nutritional 
processes of the infant and child, do more harm than good, and should 
therefore be very carefully avoided. Creosote, guaiacol, and their de- 
rivatives have long been recognized as valuable remedies in the treatment 
of tuberculosis. But these remedies, when given by the mouth to children, 
commonly do more harm than good. For this reason I have for the 
last fourteen years preferred to administer them by inunction. 1 Guaiacol 
is especially suitable to this form of administration. The prescription 
introduced by me, many years ago, is as follows : 

^ Guaiacol 3 j 

Lanolin (anhydrous) 3 [ 

Sig. Level teaspoonful externally once or twice a day. 

The technique of the application of this ointment is as follows: The 
1 American Journal of the Medical Sciences, January, 1909. 



TREATMENT 399 

skin of the chest and abdomen are carefully washed with soap and warm 
water, and, after thoroughly drying the surface, one drachm of the oint- 
ment is carefully and gently rubbed into the skin of the chest and upper 
part of the abdomen; the inunction should be continued from five to ten 
minutes. In this way the guaiacol can be introduced into the lymph 
and blood channels of the child and, passing through these circulating- 
media, can be found in the urine within two hours after the application. 
Guaiacol administered in this way is perhaps the best lymphatic antiseptic 
which we possess, and there can be no doubt but that when it is thus 
administered we get the full medicinal and constitutional effects of the 
drug without disturbing the digestive organs and without interfering 
with the healthful nutritional processes of the body. I have arrived at 
these conclusions from the use of this drug, over a long period of time, 
in a very large number of cases. In infancy the ordinary dose is one 
drachm of the ointment applied once a day; in childhood the same dose 
twice a day. My clinical experience with the use of guaiacol in this way 
leads me to the belief that it is of decided value as a therapeutic measure, 
not only in all the chronic forms of this disease but also in the acute 
processes for controlling the fever, cough and nervous s} T mptoms. 

Cod-liver oil is one of the most valuable remedies we possess, especially 
in the treatment of the chronic forms of tuberculosis in children. It is 
also of great value as a prophylactic measure in the latent tuberculosis of 
childhood, and in improving the nutrition and increasing the powers of 
resistance in delicate children having a family history of tuberculosis. 
Cod-liver oil gives the best results when administered after meals, either 
in the form of pure oil or combined with one of the malt extracts, or 
made into a palatable emulsion ; my preference is for the combination with 
one of the malt extracts. The individual idiosyncrasies of the patient, 
however, must decide not only the form in which the oil is to be given 
but also as to whether it should be given at all. Fresh syrup of the iodid 
of iron, combined with some palatable vehicle, such as a liquid diastase 
or essence of pepsin, is a very valuable remedy, especially in the chronic 
forms of lymph-node tuberculosis in older children. There is no doubt as 
to the value of iodin in this form of tuberculosis, and. if desirable, it may 
be administered by inunction, combining 5 or 10 per cent, of iodin with 
anhydrous lanolin. Inunctions of this ointment are of special .value in 
superficial lymph-node tuberculosis of the cervical lymphatics; when ap- 
plied in this way the remedy is quickly absorbed and appears in the urine 
within two hours after it is given. In the administration, however, of 
iodin in the chronic tuberculosis of childhood, I much prefer one of the 
following prescriptions : 

J£ Iodonucleoids grg . x l B Comp. syrup hypophos. . . § i 

Ferri carb. saeh 3 i S8 Syrupi hydriodic acidi. ... % { 

M. ft. chart No. 30 Liquid diastase ? ii 

Sig. One powder in half teaspoonful of Teaspoonful after eating. For 

malt ext. after meals. For a child child 6 years of age. 
6 years of age. 
07 



400 TUBEECULOSIS 

It is my belief from a clinical experience extending over a number of 
years that these two prescriptions are of signal value in the treatment of 
the chronic tuberculosis of childhood. Their continuous use influences 
favorably the nutritional conditions of the child and slowly and gradually 
improves the anemia, which is such a constant symptom. 

Arsenic given in the form of Fowler's solution combined with a suit- 
able vehicle is a remedy that exercises a favorable influence on nutritional 
processes and improves the blood state of older children suffering from 
chronic forms of tuberculosis. 

Tuberculin is of comparatively little value in the treatment of tuber- 
culosis in young children. In older children, however, it may be used in 
subacute or chronic cases in the same manner and with the same favor- 
able results as in the adult. In cases that are progressing favorably the 
injection of minute doses of tuberculin at considerable intervals lights up 
the latent foci and brings about a more rapid and more complete eradica- 
tion of this disease. (See Vaccine Therapy.) 

Cough. — The paroxysmal cough which is so common in the chronic tu- 
berculosis of childhood should be treated by the bromides and tincture of 
belladonna combined with some suitable vehicle, such as the essence of 
pepsin, great care being taken not to disturb the child's digestive organs 
with these remedies. Chloral is also a remedy of value when the cough 
is unusually troublesome, but opiates are very rarely indicated. It is best 
to use these cough sedatives only at night, and in those cases only in which 
there is such an acute exacerbation of this symptom that the child's rest 
is very much disturbed. 

Diarrhea, especially in older children, is best combated by small doses 
of oxid of zinc, one-fourth to one-half grain, combined with subnitrate 
of bismuth. Zinc oxid is a remedy of great value in controlling the 
diarrhea in intestinal and mesenteric lymph-node tuberculosis. 

Fever. — While rest is the most important agent in the control of 
fever, medical remedies may be indicated. Among these may be mentioned 
guaiacol by inunction, phenacetin, aspirin, and pyramidon. 

The treatment of tuberculosis as above outlined applies to all forms 
of tuberculosis in children which offer the hope of a favorable termina- 
tion. It is, however, especially applicable to the great group of cases 
classed under chronic lymph-node and chronic bone and joint tubercu- 
losis. It remains, therefore, only to call attention to the additional treat- 
ment which may be necessary in the special types of tuberculosis occurring 
at different ages in the life of the child. 

Cervical Lymph-node Tuberculosis. — Because of the fact that this 
form is not infrequently the only tuberculosis in the body and because 
disease of these glands does not ordinarily imply bronchial lymph-node 
tuberculosis, and especially because the diseased tissues are so accessible 
to the surgeon's knife, it is to be considered, especially in aggravated 
cases, a disease in which surgical interference offers the quickest and 
safest means of recovery. Tuberculous cervical lymph nodes which do 



TEEATMENT 401 

not yield to the general treatment for this condition should therefore be 
removed by careful dissection. There is some danger that this operation, 
if carelessly performed, may inoculate neighboring tissues and may even 
produce a general tuberculosis. Following the removal of the glands the 
long-continued application of the general principles for the treatment of 
chronic tuberculosis is necessary to produce a satisfactory convalescence, 
and careful attention to any diseased condition that may be present in the 
throat, pharynx, or nose is necessary to prevent a return of this condition. 

General Miliary Tuberculosis. — General miliary tuberculosis, 
whether it occurs in infancy or in older children, is a fatal disease, and 
the treatment, therefore, is to be symptomatic, always applying the prin- 
ciples above outlined for the general treatment of tuberculosis, in the hope 
that there may be a mistake in the diagnosis. Fresh air, proper food, 
guaiacol by inunction and the treatment of special symptoms should be 
carefully observed until a fatal termination is evident. 

Tuberculous Bronchopneumonia. — Tuberculous bronchopneumonia, 
at whatever age it may occur, should be treated by rest in bed, fresh 
air, proper food, guaiacol inunctions, the inhalation of oxygen and warm 
baths. Special symptoms, such as high fever, irritable cough and gastro- 
intestinal complications, should be dealt with in the manner outlined un- 
der the treatment of ordinary bronchopneumonia. 

Tuberculosis oe the Lungs in Older Children. — This is to be 
treated as phthisis in the adult. A quiet out-of-door life with proper food 
and all the measures previously noted in the treatment of chronic tuber- 
culosis are to be utilized. Eest in bed and suitable climatic treatment 
are more urgently demanded in this form of tuberculosis than in any 
other. High and dry air in a moderately bracing and equable climate is 
of value. The symptomatic treatment is the same as in the adult; the 
cough, fever, night sweats, and other troublesome symptoms are to be 
treated as in the adult. 

Tuberculous Peritonitis. — Tuberculous peritonitis demands rest, 
fresh air, a most carefully selected diet looking to the correction of the 
intestinal complications, guaiacol inunctions over the abdomen, and the 
careful carrying out of the general principles above outlined for the treat- 
ment of chronic tuberculosis. The treatment of this form should look to 
the correction of the intestinal complications; carbonate of guaiacol, in 
from 3- to 5-grain doses, may be administered; diarrhea may be 
treated by bismuth, and constipation by enemata. Abdominal pain may 
be relieved by the application of heat, and sometimes small doses of pare- 
goric may be necessary. Following or alternating with the inunctions of 
guaiacol one may employ inunctions of unguentum Crede, which is a 
remedy of value in many of these cases. If, however, the disease fails to 
yield to this treatment, surgical measures may be resorted to. Laparotomy 
with free drainage of the peritoneal cavity is commonly followed by im- 
provement which not infrequently continues to a final recovery. 

Tuberculosis of Bones and Joints. — This is a surgical condition, 



402 ACUTE ARTICULAR RHEUMATISM 

the special treatment of which is outlined in works on general and ortho- 
pedic surgery. The general treatment above outlined should accompany 
the surgical treatment. 



CHAPTER XLV 
ACUTE ARTICULAE RHEUMATISM AND OTHER FORMS OF ARTHRITIS 

ACUTE ARTICULAR RHEUMATISM 

Rheumatism is a general febrile disease of infectious origin, its chief 
manifestations being non-suppurative polyarthritis, acute inflammatory 
disease of the heart, and chorea. One or all of these manifestations may 
be present in the same case; any one may take precedence in the order of 
their development, but most commonly the arthritis precedes the heart 
disease and the chorea. These latter syndromes are elsewhere considered. 
Acute articular rheumatism is the term generally used to describe the 
polyarthritis and its associated symptoms produced by the infectious 
agent of rheumatism. It is most important that this broad view of the 
nature of rheumatism be kept in mind, since the articular manifestations 
in early life are sometimes so slight that it will be altogether overlooked, 
unless the general character of the disease is recognized and the impor- 
tance of other symptoms taken into consideration in making the diagnosis. 
Rheumatism in childhood is not simply an arthritis; it is a general infec- 
tion in which the arthritis may or may not play the most important role. 
For this broader view of the nature of rheumatism we are largely in- 
debted to Cheadle, Barlow and their followers. 

Etiology. — Rheumatism is generally recognized as an acute' infection, 
but as yet the specific microorganism which produces this disease has not 
been positively determined. It occurs, as a rule, sporadically, but may also 
appear in epidemic form. It is believed that the contagion usually enters 
the body through the lymphatic ring of which the tonsils and adenoids 
are a part, and in doing so may produce acute inflammation of this lymph- 
atic tissue. Heredity is an important predisposing factor. There is no 
doubt but that the members of certain families are predisposed to rheu- 
matism. This hereditary taint in many instances is related to the gouty 
diathesis. The individual may inherit arthritism, or a susceptibility to 
inflammations of serous membranes, and by reason of this inheritance 
offer but feeble resistance to the rheumatic poison. Rheumatism is more 
common in cold, moist climates and is more frequently seen during the 
spring of the year. Exposure to damp cold has long been recognized as 
an exciting factor. Rheumatism is extremely rare under two years of 
age, uncommon under five, but between the seventh and fifteenth year of 
life it is almost as frequently observed as it is in adult life. It is slightly 
more common in girls than in boys. 



ACUTE ARTICULAR RHEUMATISM 403 

Symptomatology. — In children over twelve years of age the onset is 
commonly sudden, as it is in the adult. The disease is ushered in with 
chilly sensations, followed by a rapid rise in temperature which may reach 
104° or 105° F. This is accompanied by a sharp inflammation of one of 
the ankle or knee joints. The swelling, redness, and pain rapidly increase 
until the joint becomes extremely painful to motion and exquisitely sensi- 
tive to touch. These symptoms are associated with an acid perspiration, 
and the disease quickly spreads to other joints, producing the typical 
rheumatic polyarthritis seen in the adult. The patient, prostrate and 
helpless, cries with pain when the inflamed joints are moved or touched. 
This is the picture seen in the adult, and sometimes in the older child, 
but it is in strange contrast to the clinical picture of acute articular rheu- 
matism in the young child, where the arthritis may be so slight as to 
almost escape attention, and where in many instances the child remains 
upon its feet until attention is called to its slightly tender joints and its 
slight elevation of temperature, by the development of acute endocarditis 
or some other manifestation of the rheumatic poison. Between these two 
extreme clinical pictures the severity of the disease may vary; on the 
whole, however, it should be remembered that in the child it is less vio- 
lent in its onset and much milder in its arthritis, and that cardiac mani- 
festations are much more common and severe than they are in the adult. 
The younger the child the milder the joint symptoms is a rule which may 
have its exceptions. In the average case prodromal symptoms are present, 
such as anorexia, languor, catarrhal sore throat, abdominal pain, and slight 
fever. In these prodromes there is nothing distinctive and the nature of 
the disease is not suspected until careful examination reveals tender and 
slightly swollen joints. Rheumatic polyarthritis is not so widespread in 
the child as it is in the adult. It most commonly occurs in the knee, 
ankle, wrist and elbow joints, and later may spread to the fingers, toes, 
hips and vertebra. Barlow called attention to the frequency with which 
the hip joint is involved in childhood. The acute inflammation in a joint 
rarely lasts longer than one or two days, and usually not more than two 
joints are acutely inflamed at the same time. The disease, spreading 
from joint to joint, may prolong the fever and arthritis from one to three 
weeks. Muscular pain and tenderness are common symptoms of rheu- 
matism in childhood ; they are due to inflammation of the fascia, and are 
usually more marked near the joints; many of the "growing pains" are 
due to this cause. Rheumatic wry-neck is not infrequent; it is caused by 
tonic contractions of the sternocleidomastoid, which last two or three days 
and are not intermittent, as they are in malarial wry-neck. This symp- 
tom is associated with some pain and marked tenderness of the muscle. 
Rheumatic nodules are small, fibrous nodes, varying in size from a bird- 
shot to a buck-shot, located near the joints and along the tendons. They 
are found especially about the wrists, elbows, knees, knuckles, and ver- 
tebra. They may be felt more readily than seen. When present, however, 
they are easily brought out by stretching the skin over these joints. In 



404 ACUTE ARTICULAR RHEUMATISM 

England these nodules are common and are classed among the valuable 
diagnostic signs of rheumatism in the child. In America, however, they 
are comparatively rare. Tonsillitis is a very common rheumatic manifesta- 
tion. It occurs, as a rule, as one of the initial symptoms, especially in 
second and third attacks of this disease. The anemia caused by rheumatism 
is well marked and progressive. There are few diseases that produce so 
great a destruction of hemoglobin and red blood corpuscles in the same 
length of time. Neurotic disorders are among the late manifestations ; they 
are perhaps due to the anemia and may continue for many weeks or even 
months after convalescence is established. The rheumatic child is highly 
excitable, irritable, sleeps restlessly and may suffer from night-terrors, in- 
continence of urine, habit spasm, and other neurotic disorders. The acid 
perspiration, so common in the adult, is not present in the child. 

Heart disease occurs in more than half of the cases; endocarditis is 
very common; pericarditis and myocarditis occur less frequently. These 
conditions are described in another chapter, but the facts should here be 
emphasized that disease of the heart occurs much more frequently as a 
rheumatic manifestation in the child than it does in the adult, and that 
the frequency and severity of the cardiac disease are in no way related to 
the severity of the arthritic symptoms. A case of rheumatism with little 
or no arthritis may develop a fatal heart disease. It is due, therefore, 
to the frequency and severity of the cardiac lesions that rheumatism in 
childhood is such a serious disease. Chorea is a common manifestation of 
the rheumatic poison. This syndrome may precede or follow either the 
arthritis or the heart disease. Pleurisy and iritis are rare manifestations 
of the rheumatic poison. Various skin eruptions may occur; the most im- 
portant of these are purpura, erythema multiforme, and erythema nodosum. 

Diagnosis. — If the clinical picture of this disease, as it is presented in 
childhood, be ever kept in mind, there should be little difficulty in making 
an early, accurate diagnosis. The certainty with which the salicylates 
modify or control the symptoms may, in doubtful cases, be an important 
aid to diagnosis. An acute syndrome resembling rheumatism that is not 
in any way influenced by the salicylates is, as a rule, not rheumatic. 
Again it should be remembered that rheumatism is extremely rare during 
the first two years of life, and is uncommon before the fifth year. A 
syndrome presenting joint symptoms resembling rheumatism in the adult, 
occurring in a child under three years of age, is almost without exception 
not rheumatic. Scurvy is the condition most commonly mistaken for 
rheumatism in infancy, but this is simply because the physician has in 
mind the adult type of rheumatism and has out of mind the syndrome 
of scurvy (see Scurvy). Syphilitic arthritis is an afebrile condition which 
should easily be excluded by the absence of other syphilitic symptoms. 
Septic arthritis, which occurs as a common manifestation of septicemia 
and septicopyemia, is frequently mistaken for rheumatism in childhood; 
the following clinical characteristics, however, should differentiate it from 
this disease. It follows some acute infection such as influenza, scarlet fever, 



ACUTE AETICULAE RHEUMATISM 405 

diphtheria, gonorrhea or pneumonia; the joints are acutely and sometimes 
very violently inflamed, and pus formation is common; it may run a 
more or less chronic course, the fever is septic in type, the joint symptoms 
are uninfluenced by salicylates, a blood examination shows well-marked 
leukocytosis, and the pus, aspirated from the joint, may determine the 
specific organism producing the inflammation. Acute osteomyelitis may 
be mistaken for rheumatism, but here also the high fever, marked con- 
stitutional symptoms, and pronounced swelling and tenderness which oc- 
cur near but not in the joint should make the diagnosis plain. 

Prognosis. — The prognosis, so far as the joint symptoms are concerned, 
is good. The arthritis quickly disappears, leaving the joints entirely free 
from pain and tenderness, and recurring attacks do not, except in rare 
instances, produce the chronic thickening and tenderness of the joints so 
frequently seen in the adult. The cardiac lesions, however, which are so 
commonly caused by rheumatism, are always serious and sometimes fatal. 
Treatment. — With the onset of symptoms indicating an attack of 
rheumatism, the patient should be put to bed in a well-ventilated room, 
the temperature of which should be kept between 65° and 70 °F. through- 
out the attack. As a rule it is advisable to keep the patient in bed for one 
or two weeks after all acute symptoms have disappeared. This commonly 
covers a period of four or five weeks. Eest in bed modifies the severity 
of the attack, diminishes the dangers of cardiac complications, insures a 
more satisfactory convalescence and prevents relapses. The diet through- 
out the acute attack should be milk, bread and cereals, and with the begin- 
ning of convalescence chicken and mutton broths thickened with cereals, 
purees of vegetables, and eggs may be allowed. When the joints are acutely 
inflamed they should be incased in thick layers of cotton-wool, wrapped 
with bandages, and immobilized by light splints outside the cotton-wool 
dressing. They may also be protected from the weight of the bed-clothing 
by shields. 

Medical Treatment. — This should be begun with a dose of one or 
two grains of calomel followed by Rochelle salts, and throughout the attack 
the bowels are to be kept open with sodium phosphate, sodium sulphate 
or some other saline laxative. Immediately following the preliminary 
cathartic, the salicylate treatment should be begun. In the great majority 
of cases the wintergreen salicylate of soda combined with the bicarbonate 
of soda will give the best results. But other salicylates such as aspirin 
and salol may be used. 

I£ Sodii salicylates (wintergreen) : 3 j 

Sodii bicarbonatis 3 i 

Syrupi aurantii * 3 i v 

Aquae menth pip ad ' | ij 

Sig. Teaspoonful every four hours for a child four or five years of age. 

There is no difference of opinion as to the value of salicylates in these 
cases. The only objection to their continuous administration is that it 



406 ACUTE ARTICULAR RHEUMATISM 

may nauseate and otherwise disturb the digestive organs; to avoid this 
the vehicle carrying them should be carefully selected and changed from 
time to time if necessary. The action of the salicylates in rheumatism 
is to a certain extent specific; they reduce the fever, lessen the pain, and 
perhaps shorten the attack. It is also believed that both the alkalies and 
salicylates diminish the danger of cardiac complications. As the acute 
symptoms come under control, the dose of the salicylate is to be diminished 
one-half, and continued until the fever and arthritis have entirely disap- 
peared; but the alkaline treatment is to be continued for weeks after the 
child is convalescent. If the anemia of this disease persists for two or 
three weeks after the acute symptoms have disappeared, some form of 
organic iron and of arsenic combined with malt may be given after meals. 
Cod-liver oil may also be a valuable tonic. If heart complications appear 
during the acute attack an ice-bag is to be intermittently applied over the 
cardiac region, absolute quiet insisted upon, and this complication is to be 
further treated as outlined in the section on The Heart. 

Treatment of the Interval. — If the season be winter the child 
should be sent to a warm, dry climate, to complete its convalescence. Out- 
door life in an equable, warm, dry climate will quickly restore the child's 
health and strength. On its return home in the spring of the year, the 
throat and nose should be carefully examined, and, if necessary, diseased 
tonsils, adenoids and other growths should be removed, so that during 
the summer the child's throat and upper respiratory passages can be got- 
ten into a condition to resist the common catarrhal conditions so prevalent 
during the winter months. During all of this time constipation and over- 
feeding are to be carefully avoided. It is most important that the child 
should have sufficient food of proper character to serve nutritional pur- 
poses, but in many of these children it will be found that they are taking 
from one-half to one-third more food than is actually necessary. The 
caloric value of the child's food should therefore be determined, that one 
may be sure that he is not being overfed and thus overtaxing the excretory 
organs. During all of this time he should live on a simple general diet, 
composed of vegetables, cereals, bread, meats of all kinds, eggs, cooked 
fruits and especially milk, avoiding sweets, tea, coffee, strong beef broth 
and raw food of all kinds. No medication perhaps is necessary, except an 
occasional cathartic or a course of bicarbonate of soda, or some other 
alkali, if the urine becomes hyperacid and the child becomes nervous and 
irritable. The underclothing should be of wool, and this should only be 
discarded for cotton underwear during the hot summer months. These 
children should be kept under medical supervision for years, and during 
all of this time protected from damp, cold weather, and yet be out-of- 
doors as much as possible; the best results are obtained, therefore, in 
changing the climate with the season so that they may live as much as 
possible out-of-doors in a warm, dry climate. It will not be possible to 
furnish such ideal conditions for all of our patients; most of them must 
be treated at home, but in the home treatment the same principles must 



OTHEE FOKMS OF ARTHRITIS 407 

be carried out and the physician's judgment may sometimes be taxed to 
determine in an individual case whether an indoor life will do more harm 
than exposure to the damp, cold weather, which is so prevalent during the 
winter months in the temperate zone. 

OTHER FORMS OF ARTHRITIS 

In addition to the arthritis which occurs in tuberculosis, gonorrhea, 
syphilis, scurvy, rickets, purpura rheumatica, and other hemorrhagic dis- 
eases, there are other forms which may, be confused with true rheumatism 
and which have been described under the following names : Infectious 
Arthritis, Chronic Villous Arthritis, Chronic Eheumatoid Arthritis. 

INFECTIOUS ARTHRITIS 

Infectious arthritis is an acute pyogenic infection involving one or 
more joints. 

Etiology. — It commonly occurs as a symptom or complication of the 
acute infections, such as tonsillitis, scarlet fever, influenza, diphtheria, 
pneumonia, cerebrospinal meningitis, and septicopyemia. It may be pro- 
duced by a variety of microorganisms, the most common of which are 
streptococci, staphylococci and pneumococci. 

Symptomatology. — The joint or joints involved become swollen, red, 
tender, and fluctuation sooner or later develops. The aspirating needle re- 
veals the character of the fluid, and from the fluid thus obtained the spe- 
cific organisms producing the inflammation may be isolated. The fever 
in these cases is irregular or septic in type ; the pain and tenderness of the 
joints and the fever are uninfluenced by salicylates, and the blood shows 
a marked leukocytosis. Infectious arthritis may be associated with or 
may follow osteomyelitis. In such cases the constitutional symptoms are 
much more pronounced, there is evidence of general sepsis and the swell- 
ing and tenderness extend from the joints into the bones. 

Treatment. — This is a surgical condition and operative measures are 
usually necessary for its relief. Following the opening and draining of 
the infected joints, if convalescence does not readily set in, autogenous 
vaccines should be tried. In most cases recovery is followed by more or 
less complete ankylosis. Later when all inflammation has subsided mas- 
sage and active and passive motion of the joint may be resorted to, in the 
hope of partially restoring its function. 

CHRONIC VILLOUS ARTHRITIS 

Chronic villous arthritis is a low inflammatory affection of the synovial 
membranes, which results in hypertrophy of the villi of the joint surfaces ; 
one or more joints may be involved. The etiological factors of this con- 
dition are unknown, but it is not uncommonly associated with other joint 
diseases. 

Symptomatology. — There is little or no fever, the disease runs a very 



408 ACUTE AETICULAE RHEUMATISM 

chronic course, the joints involved gradually increase in size and assume 
a more or less waxy appearance ; they are slightly tender, and after a time 
become more or less ankylosed and remain chronically enlarged. This 
condition may be mistaken for a tuberculous arthritis, but the absence of 
other signs and symptoms of tuberculosis, together with an X-ray pic- 
ture showing no bone changes in the joints involved, should clear the 
diagnosis. 



CHRONIC RHEUMATOID ARTHRITIS 

(Arthritis Deformans, Still's Disease) 

Under the above names are described a group of comparatively rare 
arthritides which occur in children, involving, as a rule, many joints, run- 
ning a very chronic course and leaving the joints more or less disabled. 

Etiology. — This condition may be associated with chronic intestinal 
intoxication, some defect in metabolism or some more or less obscure 
infection. 

Symptomatology. — The onset may be sudden or it may be gradual, but 
in all of these cases in the beginning there is fever, mild or severe, with 
more or less soreness, pain and swelling of the joints of both the upper and 
lower extremities. After a time the acute inflammatory symptoms in the 
joints gradually subside, leaving them more or less deformed or disabled. 
In some cases there are repeated attacks of acute inflammation of the 
joints marked by increased swelling, tenderness, and perhaps by a slight 
rise of temperature. With these repeated attacks the joints are left more 
and more deformed and disabled. In one group known as Hypertrophic 
Arthritis the condition resembles arthritis deformans; in these cases the 
bones about the joint hypertrophy, exostoses form, a marked nodular 
deformity of the joint results, and its function is gradually lost. In 
another group, spoken of as Atrophic Arthritis, the tissues about the joint 
atrophy, and ankylosis occurs from the inflammatory adhesions of the joint 
surfaces; in these cases the nodular deformities about the joint are not 
so great. In a third group, StilFs Disease, there is associated with 
the rheumatoid arthritis enlargement of the lymph nodes, spleen, 
and sometimes the liver, and marked leukocytosis is present; the 
lymph nodes especially enlarged are the axillary, epitrochlear and posterior 
cervical. 

Prognosis. — The prognosis so far as life is concerned is good, but the 
majority of these cases become crippled and deformed. A certain per- 
centage, however, especially those associated with chronic intestinal intox- 
ication, may be greatly benefited and a small percentage entirely recover. 

Treatment. — If the underlying intoxication can be discovered, treat- 
ment should be directed toward its removal. It is most important in 
all cases to give attention to the gastrointestinal canal. Careful feeding 



OTHER FORMS OF ARTHRITIS 409 

to suit the age and digestive capacity of the individual and fresh air, 
night and day, are our most important remedial measures. During the 
acute inflammatory stage of the arthritis the joints should be fixed and 
carefully protected by appropriate dressings. After the acute stage has 
disappeared and all tenderness and evidences of inflammation in the joints 
have subsided, massage, passive movements, and hydrotherapy may be of 
value in partially restoring the lost motion. 



SECTION VII 

DISEASES OF THE RESPIRATORY SYSTEM 

The nasal cavity of the young child is much smaller than that of the 
adult. In the newborn it is so narrow that slight swelling of the mucous 
membrane may cause its occlusion. The accessory sinuses of the nose are 
but poorly developed, so that one rarely sees in the infant and very young 
child infections of the ethmoidal and frontal sinuses. On the other hand, 
the Eustachian tube is unusually patulous, in the young child, so that in- 
flammatory processes of the pharynx are much more readily communicated 
to the middle ear. The tear ducts in the infant and child are also more 
patulous, and more readily carry inflammation from the nose to the eye. 
Catarrhal inflammations, therefore, of the ear and the conjunctiva are 
much more common complications of the catarrhal diseases of the respira- 
tory passages in the young child than they are in the adult. The thorax 
is more cylindrical than in the adult, and the ribs are soft and flexible, 
being composed largely of cartilaginous tissue. This flexibility makes it 
possible, when there is difficulty in getting air into the lungs, for the 
diaphragm, by reason of its forceful contraction, to cause the chest to sink 
in and produce the peripneumonic groove where the diaphragm is at- 
tached to the chest wall. This peripneumonic inspiratory recession of the 
chest is one of the characteristic signs of dyspnea in the young infant. 
The softness and pliability of the ribs in early infancy is more marked in 
rachitic infants. Children of this type, when subjected to more or less 
inspiratory obstruction over a long period of time, may have chronic 
deformities of the chest, such as pigeonbreast and depressions of the chest 
wall about the lower end of the sternum. 

The respiratory rhythm, like the heart rhythm of the young infant, 
may be very irregular without indicating a pathological condition. The 
frequency of respirations, like the pulse rate of the infant, may be affected 
by insignificant causes, and varies greatly within normal limits. Excite- 
ment, anger, slight toxic conditions, and even reflex irritations caused by 
pain in the intestinal canal, the ear, or elsewhere may produce a marked 
acceleration of the respiratory rate. 

The thoracic muscles of the infant are poorly developed, but the dia- 
phragm and abdominal muscles are well developed. The child breathes 
and cries with its diaphragm and abdominal muscles. The type of breath- 
ing in both sexes is largely abdominal. The costal type commences to be 

410 



ACUTE EHIXITIS 411 

manifest in the male child at about the ninth or tenth year of life. The fol- 
lowing table shows the comparative frequency of the pulse and respira- 
tions at different periods of child life : 

Infant. 1st to 2d year. 4th to 6th year. 8th to 10th year. 

Respiration 50-30 25 20 18 

Pulse 130-120 100-95 90 85 

Ratio 1 to 3 or 4 1 to 4 1 to 4% 1 to 4% or 5 



CHAPTEE XLVI 
DISEASES OF THE NASAL MUCOUS MEMBRANE 

ACUTE RHINITIS 

(Acute Coryza, Acute Nasal Catarrh) 

This is a catarrhal inflammation of the nasal mucous membrane which 
very commonly involves the pharynx and tonsils. 

Etiology. — Infection is the prime and all-important cause of rhinitis. 
This catarrhal inflammation may be produced by a great variety of micro- 
organisms, chief among which are the pneumococcus, streptococcus, staphy- 
lococcus, bacillus catarrhalis, and influenza bacillus. It may also be 
caused by the pathogenic organisms which produce measles, diphthe- 
ria, scarlet fever, and cerebrospinal meningitis; rhinitis, therefore, 
is a lesion producing a rather definite clinical syndrome, rather than a 
disease sui generis. While microorganisms are the essential cause of this 
condition, it should be remembered that the mucous membrane of the nose 
is normally in a condition to resist infection from most of these organ- 
isms; in fact the bacteria capable of producing a rhinitis may usually be 
found on the nasal mucous membranes of normal children. At times the 
disease occurs in epidemic form, being produced by the bacteria of epi- 
demic grippe, but the fact that the ordinary or sporadic form is not in- 
frequently produced by microorganisms which the normal mucous mem- 
brane of the nose is capable of resisting, shows the importance of predis- 
posing factors. These factors may produce a trauma, a congestion, or an 
irritation of the nasal mucous membrane or, by acting through constitu- 
tional influences, may so reduce its resisting power that bacteria which are 
commonly present are enabled to start an acute catarrh and develop a 
well-marked rhinitis. Among these predisposing causes may be mentioned : 
traumas to the mucous membrane from chemical and mechanical causes, 
exposure to dry air in superheated apartments, or, more important than 
all, exposure to damp cold, unprotected by proper clothing. This latter 
predisposing cause is the one ordinarily spoken of by the laity as "catching 
cold," and there can be no question but that it is an important and com- 



412 DISEASES OF THE NASAL MUCOUS MEMBRANE 

mon predisposing cause not only of rhinitis, but of all catarrhal diseases 
of the respiratory mucous membranes. 

Ehinitis is most common in the cold, damp months of winter and 
spring, because the conditions for "catching cold" and for contracting 
contagion are very much better during these seasons. Mild cases of rhi- 
nitis are also very common during the dry fall months of the year, when 
the mucous membrane is so constantly irritated with a dust-laden at- 
mosphere. The particles of dust may act as carriers of bacteria and as 
irritants to the mucous membrane, thus preparing the soil for the seed 
which is carried to it. Subacute or chronic diseases of the tonsils and 
adenoid tissues may be the cause of repeated attacks of rhinitis. Constitu- 
tional diseases, especially syphilis and tuberculosis, are so commonly asso- 
ciated with rhinitis that this symptom group is described as a part of the 
symptomatology of these two diseases. Other malnutritions which produce 
anemia and diminish the general resistance may be predisposing causes. 
Ehinitis is one of the important symptom groups of hay fever. There is 
a recurring form, probably due to autotoxins, which is described under 
Nutritional Disorders. 

Symptomatology. — The onset is marked by an irritation of the mucous 
membrane of the nose, which manifests itself by redness and swelling; 
sneezing is a common and early symptom. As a rule there is a slight 
elevation of temperature associated with headache, lassitude, sleeplessness, 
nervousness, and more or less general discomfort. Early in the disease 
the nasal discharge is thin and watery, being serous in character. In a 
few days this discharge becomes thicker and more tenacious, being com- 
posed of heavier mucus; later it may become mucopurulent. In gonococ- 
cic, diphtheritic and scarlatinal infections the discharge is always puru- 
lent. The irritating character of the discharge in ordinary rhinitis varies 
greatly. Not infrequently the nasal openings and the underlying portion 
of the lip, over which the discharge runs, are irritated, red, excoriated and 
sometimes covered with dry scales, or scabs, which may partially or com- 
pletely block up the nasal opening. Rhinitis is a comparatively insig- 
nificant disease, which runs a mild course, terminating in recovery in 
from three to five days. The great majority of the cases are fortunately 
of this type. In the very young infant the disease is much less commonly 
seen, but when it does occur it is a source of much greater anxiety to the 
physician, not only because it is more likely to extend through the pharynx 
to the bronchial mucous membrane, but also because even simple rhinitis 
at this age is a troublesome, sometimes serious, and rarely dangerous af- 
fection, because the swelling of the nasal mucous membrane not 
infrequently occludes the narrow nasal passages of the young infant, and 
when this occurs it may have great difficulty in sleeping, breathing, and 
taking food. The very young infant, not being accustomed to breathe 
through its mouth, may be put in a perilous position by having its nasal 
passages occluded; dyspnea, severe attacks of asphyxia, and, in rare in- 
stances, even death may result from nasal stenosis; this, however, is a very 



ACUTE RHINITIS 413 

rare occurrence. The taking of food in these cases is always more or less 
interfered with; the infant often cannot nurse either from the breast or 
from a bottle, since it must let go of the nipple to get its breath; it may 
be necessary to feed with a spoon. 

Cough. — In simple, uncomplicated rhinitis cough is usually absent, 
but in the majority of cases the disease extends to the pharynx and some- 
times to the larynx. Irritation in either of these regions may produce a 
cough, the character of which may mark the progress of the disease. The 
pharyngeal cough frets the infant and is sharp and irritating; as the 
disease progresses into the larynx, the characteristic croupy cough, later 
to be described, makes its appearance. 

Fever. — Ehinitis may run its course with little or no fever; however, 
there is usually a slight elevation of temperature in the beginning of the 
disease. In the epidemic forms associated with grippe and other con- 
tagious diseases the temperature at the onset may be high; this is not due 
to the coryza, but to the general infection of which the coryza is a symp- 
tom. Later in the disease, as the rhinitis is running its course, apparently 
in a satisfactory manner, we may have a sudden and marked elevation of 
temperature, the fever reaching 104° or 105°F. within a few hours; this 
commonly means the onset of an acute otitis media. This complication 
demands immediate surgical attention; an early incision of the drum 
may save not only much surf ering, but a possible mastoid infection. Ear- 
ache commonly precedes the otitis media ; but in some instances, especially 
in malnourished, tuberculous children, a discharge from the ear is the 
first indication of this complication. 

Pharyngitis, tonsillitis, and inflammation of the adenoid tissue of the 
pharynx are frequently associated with coryza. Catarrhal inflammation 
in the nose not infrequently spreads to the eye, producing a mild, or even 
a pronounced, conjunctivitis; this may occur in epidemic form, and is 
then commonly spoken of as "pink eye." The conjunctivitis may precede 
the coryza, but commonly the reverse is true. 

Pseudomembranous rhinitis should always be looked upon as diph- 
theritic, until it has been definitely demonstrated to be due to other causes. 
The safest plan in these cases is to give a dose of diphtheria antitoxin, and 
later determine by a bacteriological examination whether the membrane 
is diphtheritic or due to diplococci, streptococci, staphylococci, or other 
microorganisms. The bacteriological examination, in fact, in these cases 
is not always to be relied upon. In cases of simple rhinitis I have seen capa- 
ble bacteriologists demonstrate bacilli which could not be differentiated from 
diphtheria bacilli, and in advanced cases of diphtheria of the nose I have 
seen them fail to differentiate the specific microorganism of this disease. It 
is wise, however, in every case of severe rhinitis, associated with marked 
irritation and constitutional symptoms, to make a bacteriological examina- 
tion, and if diphtheria bacilli are found, membrane or no membrane, 
antitoxin should be given. 

Prognosis. — The prognosis in the vast majority of cases is good; the 



414 DISEASES OF THE NASAL MUCOUS MEMBRANE 

disease runs a short and benign course and terminates in recovery. In 
the diphtheritic and other pseudomembranous forms the disease may ter- 
minate fatally. The prognosis in these cases largely depends upon the 
treatment. During the first year of life even simple rhinitis may become a 
dangerous disease which occasionally terminates fatally. 

Chronic rhinitis, as compared with its frequency in the adult, is un- 
common in the infant and young child. Chronic nasal catarrh rarely 
supervenes upon the acute process except in tuberculous and syphilitic chil- 
dren, or in those who have chronic disease of the tonsils or adenoids. A 
relapsing, or chronic coryza in an otherwise healthy infant usually means 
chronic disease of the adenoid tissues of the pharynx. 

Prophylaxis. — As rhinitis is an air-borne disease, due primarily to in- 
fection, and secondarily to causes which irritate the nasal mucous mem- 
brane, the prophylactic treatment consists in keeping the child in fresh air 
day and night. It should live in the open as much as possible during the 
day, and sleep in a well-aired room at night. Well children should be kept 
away from sick ones. Infants and young children should be kept out of 
closed street cars and places of amusement, where large numbers of 
people are crowded together in a close, overheated atmosphere. Re- 
curring attacks of rhinitis may require the removal of diseased tonsils and 
adenoids. 

Treatment. — Children suffering from simple rhinitis should be kept 
out of doors in the fresh air, away from dusty streets and roads, that they 
may breathe pure air, free from germs, dust, and other irritating im- 
purities. Living indoors and breathing warm, dry, impure air aggra- 
vate the disease. Nasal injections of some mild alkaline antiseptic are 
of value, especially in older children; they should be given with a soft 
all-rubber syringe, the child's head being inclined forward with the face 
looking downward, and the fluid gently and slowly injected into the an- 
terior nares in such a way that the mucous membrane of the nose and 
pharynx may be irrigated. If the child is not old enough to accomplish 
this operation without a struggle, it is better not to attempt it at all; 
these same antiseptic applications may be almost as effectively applied 
with atomizers; this is preferable to the nasal injections in young chil- 
dren. Inhalations of cresolin, tincture of benzoin, guaiacol and oil 
of turpentine may be used to advantage in steam atomizers. In every 
case of rhinitis, both in infants and older children, the following prescrip- 
tion may be instilled into the nose, four or five drops three or four times 
a day : Oil of eucalyptus, m. 10 ; menthol, gr. y 2 to 1 ; liquid albolene 
enough to make an ounce. This is an effective remedy, which may be used 
even in the newborn. If in a given case the mucous membrane of the 
nose be very raw and irritated, the menthol may for a time be left out of 
the prescription; it is, however, an effective antiseptic, and in the dose 
above given is usually not irritating. In cases where there are great irrita- 
tion and swelling of the mucous membrane of the nose the following pre- 
scription may be used: 



EPISTAXIS 415 

I£. Cocain hydrochloric! g r { 

Adrenalin sol. (1 to 1,000) 3 j 

Boric acid grs x 

Distilled water ad | i 

From three to five drops of this mixture may be dropped into the nose 
at intervals of three or four hours. It has a sedative action and tends to 
relieve the engorgement of the mucous membrane. An ointment of lanolin 
containing 1 per cent, of boracic acid is a soothing application to the ex- 
ternal nares and upper lip when these parts are irritated and excoriated. 
This may be used on pledgets of cotton or gauze to remove the crusts 
and cleanse the external nasal canal. In desperate cases in very young 
infants a small, soft catheter has been recommended for introduction along 
the nasal canal to prevent its complete closure. In even more desperate 
cases tracheotomy has been resorted to to save the life of the suffocating 
infant. These extreme measures are very rarely necessary. 

With the local treatment above recommended, a number of drugs may, 
in selected cases, be used internally. In older children quinin is of de- 
cided advantage, and is to be given in pill form, if possible. If the child 
be too young for this, one or two grains of euquinin may be given at three 
or four-hour intervals. In infants under eighteen months of age the fol- 
lowing prescription may be used : 

Guaiacol carb grs. xii 

Salol grs. xii 

Sugar grs. xii 

Make 12 powders. 

One every three or four hours. 

The treatment of chronic rhinitis comprehends the use of all the rem- 
edies above mentioned, and in addition the removal of the underlying 
cause. This is usually some constitutional disease such as tuberculosis or 
syphilis, or some chronic local disease such as hypertrophied adenoids and 
tonsils. With the removal of these conditions, chronic and recurring 
rhinitis in the child usually disappear. 

EPISTAXIS 

Nose-bleed is rare in young infants. It may occur during the first 
days of life as a symptom of syphilis or sepsis. 

Etiology.' — The exciting cause is commonly some injury to the mucous 
membrane of the nose produced by contusions, by foreign bodies or by 
other traumas. But the direct exciting causes, in the majority of instances, 
are of less importance than the predisposing causes, since by them the 
mucous membrane is put in such a condition that it bleeds from the slight- 
est injury. Among the predisposing causes are adenoid vegetations, nasal 
catarrh and ulcerations of the nasal mucous membrane. In certain infec- 
tious diseases, such as typhoid fever, measles, influenza, scarlet fever and 
28 



416 DISEASES OF THE NASAL MUCOUS MEMBKANE 

whooping-cough, nasal hemorrhages are common. They occur also in 
certain constitutional diseases, such as hemophilia, purpura hemorrhagica, 
peliosis rheumatica and grave forms of anemia, and scurvy. Where the 
predisposing causes are marked, nasal hemorrhages may sometimes be pro- 
duced by stooping and by violent exercise, or they may be spontaneous; 
that is to say, the exciting causes are not discoverable. 

Hemorrhages occurring from the back part of the nose may, especially 
in infants, cause the blood to flow into the pharynx, where it is swallowed, 
and produces a dark discoloration of fecal discharges. Nasal hemorrhage 
unassociated with constitutional disease is rarely severe enough to pro- 
duce marked anemia or general weakness. In purpura hemorrhagica, 
severe toxemia, and hemophilia nose-bleed may become dangerous. In the 
majority of cases the bleeding point may be located by an examination 
with a nasal speculum. 

Treatment. — In most instances no treatment is required; the bleed- 
ing stops spontaneously after a short time; the home remedies, such as 
swallowing salt and cold applications to the back of the neck, occupy the 
attention of the family until the hemorrhage ceases. The most effective 
remedy for the relief of nasal hemorrhage is the injection through the 
nasal canal of an adrenalin solution after the clots have been removed ; for 
this purpose the 1 to 1,000 solution may be diluted ten times and injected 
through the nose with a soft rubber syringe; this same solution may be 
applied on pieces of cotton or on strips of gauze which are pushed into the 
nose beyond the bleeding point. Other remedies are rarely, if ever, needed 
for the control of ordinary nasal hemorrhage. Bleeding from the nose may 
very commonly be stopped by the simple introduction of pledgets of dry cot- 
ton, without the use of medicines to contract the bleeding vessels. In cases 
of nasal hemorrhage associated with severe hemorrhagic constitutional dis- 
eases it may be necessary to tampon the whole nasal cavity with gauze, sat- 
urated with adrenalin solution. In recurring attacks of epistaxis the bleed- 
ing point in the nose may require cauterization in the interval between 
attacks. 

FOREIGN BODIES IN THE NOSE 

Young children very frequently push small foreign bodies into the 
nose, such as buttons, grains of corn, beans, pebbles, beads, and other small 
objects with which they play; thus lodged in the nostrils they often re- 
main for days or months before they are discovered. Foreign bodies in 
the nose produce more or less occlusion of the nasal passage, and as a re- 
sult a unilateral rhinitis occurs; this may be severe enough to produce 
a very decided inflammatory process with ulceration. In the great ma- 
jority of instances the foreign body is discovered before it has produced 
marked inflammation, and its removal from the nose is, as a rule, a simple 
process. If the child be old enough it may, by closing the opposite nos- 
tril, force the body out by blowing the nose; in most instances it can 



DISEASES OF TONSILS 417 

readily be seen and pulled out with a pair of fine forceps. If its shape 
be such that it cannot be grasped by forceps, it can be removed by intro- 
ducing a small probe which is bent very slightly at the end; this may be 
passed beyond and hooked over it. In some instances it may be neces- 
sary, where the swelling and inflammation are great, to relieve the sensi- 
tiveness of the mucous membrane by the application of cocain. Where 
the foreign body is so far back in the nasal passage that it cannot be re- 
moved in one or the other of the ways described, it may be pushed with 
a small, cotton-wrapped probe back into the pharynx, being careful that 
it does not drop into the larynx or trachea. 



CHAPTEE XLVII 

DISEASES OF TONSILS 

The faucial tonsils are a part of Waldeyer's lymphatic ring which ex- 
tends around the pjiarynx, and includes the pharyngeal tonsil (adenoids) 
and, later in life, the lingual tonsil. These tonsils are masses of lymphoid 
tissue which are held together by intervening connective tissue. In the 
infant and young child the pharyngeal tonsil (adenoids) is most com- 
monly affected by disease. In childhood the faucial tonsils, which are 
comparatively inactive during infancy, are. very commonly diseased, and 
later in life the lingual tonsil may be a source of trouble. The faucial ton- 
sils, whose function is more or less obscure, are filled with crypts and con- 
tain a large number of mucous glands. The irregularity of their sur- 
face, as well as their mucous coating, enables them to stand guard at the 
entrance to the throat and prevent microorganisms and other disease- 
producing factors from entering the pharynx; the microorganisms thus 
picked up are usually cared for in a satisfactory manner by the normal 
tonsil without producing disease. There can be no question but that the 
tonsils, especially in children, serve an important purpose in preventing 
contagion. The crypts very commonly contain not only mucus and par- 
ticles of food, but large numbers of pathogenic microorganisms, including 
pneumococci, diplococci, streptococci, staphylococci, and bacilli catarrhalis, 
any of which are capable of setting up inflammatory processes in the mucous 
membrane of the respiratory passages; even when the tonsil itself becomes 
diseased or infected, the infection is rarely transmitted directly to internal 
organs. Jacobi called attention to the fact that while Waldeyer's lymphatic 
ring is one of the important gateways through which infections of various 
kinds enter the body, the entrance is not effected, as a rule, directly 
through the faucial tonsils, but when other portions of this lymphatic 
ring are affected, then there is great danger of the contagion obtaining 
entrance to the general lymph or blood streams, and producing thereby 
general constitutional diseases or localized infections of internal organs. 
The late Dr. Frederick Packard called attention to the fact that tonsillitis 



418 DISEASES OF TONSILS 

very frequently preceded or was associated with endocarditis, rheumatism 
and other infections. While the normal tonsil may serve the important 
purpose of protecting the infant from contagious diseases of various kinds, 
the hypertrophied and chronically diseased tonsil, harboring in its crypts 
infectious microorganisms, frequently becomes a menace to the health of the 
child rather than a protecting agency against disease. In such tonsils re- 
peated attacks of tonsillitis may occur from slight predisposing causes with- 
out new infection. These are the cases that are most closely associated with 
endocarditis, chorea, and acute rheumatism; and with successive attacks of 
ulcerative tonsillitis there may be repeated attacks of arthritis, endocar- 
ditis, or chorea. The lymphoid ring, of which the tonsils are a part, is in 
close communication not only with the retropharyngeal lymph glands, but 
also with the cervical lymphatics situated below the angle of the jaw, 
along the lines of the great vessels of the neck. In diseases of this lymphoid 
ring, therefore, the cervical lymph nodes below the angle of the jaw are 
more or less swollen; the retropharyngeal lymph nodes are more closely 
connected with the pharyngeal tonsil, and the cervical lymph nodes with 
other portions of this lymphatic ring, including the faucial tonsils. From 
what has been said, it is evident that tonsillitis, pharyngitis, and adenoid 
disease are very commonly a part of the same pathological process. In 
the infant and young child practically every tonsillitis is accompanied by 
more or less pharyngitis, although the reverse of this is not true. 

TONSILLITIS 

Acute Follicular Tonsillitis. — Etiology. — Acute follicular tonsillitis 
is an infectious disease which may be produced by a number of pathogenic 
microorganisms, chief among which are diplococci, streptococci, staphylo- 
cocci, pneumococci, micrococci catarrhalis, and influenza bacilli. It not in- 
frequently occurs as an epidemic, spreading through families, schools, and 
institutions for children. It is very commonly an important part of the 
syndrome of some of the acute infections, such as scarlet fever, influenza, 
rheumatism and measles. Any of the above-named microorganisms may be 
held for a long time in the tonsillar crypts, until an exciting cause starts 
them into activity; recurring attacks of tonsillitis are usually produced in 
this way. "Catching cold" and traumatism are exciting causes, which can 
produce tonsillitis only when the contagion is present in the tonsillar crypts. 
In infants it is also believed that the fermenting contents of a disordered 
stomach may be the exciting cause. On the other hand, there can be no 
question but that gastrointestinal indigestion and infection are very com- 
monly secondary to tonsillitis, the infected mucus when swallowed being 
the exciting cause. 

Certain constitutional diseases, such as tuberculosis, the lymphatic 
diathesis, rheumatism, and gout, may predispose to tonsillitis. 

Symptomatology. — In the infant and young child, not able to locate 
its pain, or point out the site of the disease, tonsillitis may be overlooked, 



TONSILLITIS 419 

unless the physician adopts the rule of carefully inspecting the throat of 
every sick child. It usually announces itself with fever, pain, general dis- 
comfort, and in some instances with more or less marked prostration. 
The fever may rise as high as 102° or 104° F., and usually lasts from two 
to four days; during this time there may be marked irregularities of the 
temperature. There is nothing specific in the temperature curve, but it is 
important to remember that more or less fever is a symptom of every case 
of tonsillitis, and that if it lasts longer than five or six days there is prob- 
ably some complication, such as otitis media, suppuration of lymph glands, 
or the spread of the inflammation from the tonsils to some other portion of 
the respiratory passages. The fever is accompanied by malaise, headache, 
backache, and sometimes is associated with a chill; chilly sensations are 
very common in older children. Young infants take their food badly, 
nurse with difficulty, and their breathing may be more or less obstructed, 
especially during sleep. Older children may complain of sore throat and 
pain in swallowing; the lymph nodes at the angle of the jaw are enlarged. 

The diagnosis is made by an inspection of the throat. The tonsils are 
red and swollen; the neighboring mucous membranes of the pharynx and 
pillars of the soft palate may also be inflamed, and all of these tissues 
may be covered with a mucopurulent discharge. In almost every case of 
tonsillitis not only the parenchyma, but the glandular structures of the 
mucous membrane, are involved, and sooner or later small grayish-white 
spots are to be seen scattered over both tonsils; these may enlarge, run 
together, and form irregular, grayish-yellow patches, which are thin, and 
cling lightly to the tonsillar tissue, Ailing the crypts and in some instances 
covering the greater portion of the tonsillar mucous membrane. Between 
the membranous deposits, however, strips and patches of swollen and red 
mucous membrane may usually be seen. More rarely a pseudomembrane, 
croupous, but non-diphtheritic in character, may form. 

Ulceromembranous Tonsillitis. — Ulceromembranous tonsillitis, or Vin- 
cent's angina, is a form of tonsillitis produced by the symbiotic action 
of Vincent's bacillus and spirillum. The bacillus is fusiform in shape, 
shows transverse markings, has pointed ends, and is much longer than 
the diphtheria bacillus. The spirillum is slender and usually has three 
or four whorls. Vincent's angina is much less common, runs a milder 
course and has fewer constitutional symptoms than ordinary follicular 
tonsillitis; it not infrequently involves only one tonsil. The diagnosis is 
made by finding the microorganisms, which are readily detected in smear 
preparations, and by the presence of a grayish-yellow ulcer on one or both 
tonsils, which usually varies from one-fourth to one-half inch in diameter, 
but may cover the whole tonsil. This form of tonsillitis may be associated 
with a membranous stomatitis of the same character. 

Cause and Prognosis. — Follicular tonsillitis usually runs its course 
in from three to five days. Following the acute symptoms, there may 
be a rather slow convalescence covering a week or ten days, during which 
time the patient recovers his appetite and strength, and the tonsils grad- 



420 DISEASES OF TONSILS 

ually diminish in size and resume their normal color and appearance. In 
Vincent's angina the disease runs a longer course, and convalescence is 
delayed. 

The prognosis in all forms of acute tonsillitis is good; the great ma- 
jority of these cases recover without complications. It should be remem- 
bered, however, that otitis media, peritonsillitis, chorea, endocarditis, and 
septic arthritis are dangerous complications which may possibly occur. The 
danger from these complications, as previously noted, is much greater in 
the frequently recurring attacks of acute follicular tonsillitis associated with 
chronic tonsillar hypertrophy. 

Differential Diagnosis. — With the onset of every tonsillitis, the physi- 
cian should be on the lookout for influenza, scarlet fever, and diphtheria. 
From influenza and scarlet fever acute tonsillitis is differentiated by the 
general symptom-complex of these diseases. From diphtheria, however, 
it is practically impossible in many cases to make a differential diagnosis, 
except by a bacteriological examination. In all cases of tonsillitis which 
clinically resemble diphtheria it is wise to give a dose of antitoxin with- 
out waiting for the bacteriological examination to determine the presence 
or absence of Klebs-Loffler bacilli. In the great majority of cases the 
pictures presented by true tonsillar diphtheria and acute follicular ton- 
sillitis are fairly distinct. In diphtheria the exudation presents the ap- 
pearance of a membrane covering all or part of the ulcerated tonsil; it is 
dark gray in color, and so closely attached that any effort at its removal 
produces bleeding. In addition to the large membranous patch small 
patches similar in character may be seen on the uvula or pharynx. This 
picture is very different from the widely disseminated, grayish-white, small 
patches seen in follicular tonsillitis, and even when these enlarge and 
coalesce to form larger patches of membrane the exudate thus formed is 
rather loosely adherent, and, as a rule, easily removed without producing 
hemorrhage. The differential diagnosis in difficult cases must be made 
first by the response of the disease to antitoxin, and second by a bac- 
teriological examination of the throat. 

CHRONIC TONSILLAR HYPERTROPHY 

This is the condition previously referred to of chronically enlarged and 
diseased tonsils, so frequently seen in children who have suffered from 
repeated attacks of tonsillitis. It is commonly associated with chronic 
disease of the adenoids and with more or less chronic hypertrophy of 
the entire lymphoid ring of the pharynx. A small percentage of these 
cases is due to the tubercle bacillus. 

Symptomatology. — Patients suffering from chronic tonsillar hyper- 
trophy commonly lack strength, are malnourished, anemic, and have poor 
chest development. They are restless, nervous, sleep poorly and commonly 
speak with an altered nasal tone, and many are mouth-breathers from 
complicating adenoids. The lymphatic glands at the angle of the jaw 



PERITONSILLAR ABSCESS 421 

are chronically enlarged. The diagnosis is made by an examination of 
the throat. The tonsils are enlarged and covered with irregular deep 
crypts, in which not infrequently caseous material accumulates, presenting 
the appearance of isolated white patches. In such cases the breath is offen- 
sive and the caseous material, when removed by a dull instrument, has the 
same bad odor. These are the cases in which the tonsils no longer act as 
safeguards against infection, but are an actual menace to the health of 
the child, subjecting it to the dangers of tonsillitis, middle-ear infection, 
endocarditis, arthritis, diphtheria, scarlet fever, and other infections. 
There is little doubt but that in many of these cases in which there is 
great chronic enlargement of the tonsils this condition acts injuriously 
upon the health of the child by mechanically interfering with the respira- 
tion and producing a low form of chronic toxemia. Chronic tonsillar 
hypertrophy may be a symptom of the lymphatic diathesis; in such cases, 
like the anemia, malnutrition, and lack of development, it is an expression 
of a general constitutional disorder. 

PERITONSILLAR ABSCESS 

Peritonsillar abscess, or quinsy, is comparatively rare in infancy and 
young childhood. The microorganisms producing this abscess are ap- 
parently the same varieties of streptococci and staphylococci found in 
ordinary tonsillitis, and yet the disease not infrequently occurs in epi- 
demic form. That is to say, in certain epidemics of tonsillitis, quinsy 
may be common; in others it may be a rare occurrence. Individuals who 
have had one attack of quinsy are much more liable to second and third 
attacks. The disease usually occurs on one side; it may, however, be 
bilateral. 

Symptomatology. — Fever, chilly sensations and a painful sore throat 
mark the onset of quinsy. The pain becomes very severe, is throbbing 
in character, and is very much aggravated by swallowing and talking. 
There is great tenderness and more or less swelling and tumefaction be- 
neath the angle of the jaw in the region of the tonsil. Difficulty is ex- 
perienced in opening the mouth. 

Diagnosis. — The diagnosis is made largely upon the fact that the pain 
is out of all proportion to the appearance of the throat on examination. 
The follicular tonsillitis, which may have been present in the beginning, 
has entirely disappeared, but the tonsil, and especially the supra-tonsillar 
tissue, remains red and edematous, and on examination with the ringer, 
fluctuation may be found. The abscess continues to increase in size, and 
if not opened breaks spontaneously after several days, and discharges into 
the throat a quantity of pus, more or less tinged with blood. The relief 
which follows the evacuation of the pus is very great, and convalescence 
is usually rapidly established. 



422 DISEASES OF TOXSILS 



TREATMENT OF DISEASES OF THE TONSILS 

Treatment of Follicular Tonsillitis. — With the onset of acute symptoms 
the child should be put to bed and isolated. A liquid diet suitable to its 
age should be selected, not only with reference to protecting it from gas- 
trointestinal complications, but also with the idea of throwing as little 
work upon the excretory organs as possible. A milk and cereal diet is 
to be recommended at the onset, until it is definitely determined that the 
tonsillitis is not the beginning of scarlet fever, diphtheria, influenza, or 
some other acute infection. When it has been decided that only a simple 
follicular tonsillitis is present, the diet in older children may be increased 
to suit the demands of the child. In most instances the difficulty in swal- 
lowing causes the child to refuse food. In older children ice-cream, thick 
gruels, milk-toast, and soft, semi-solid food are more grateful and more 
easily taken than milk alone. The rest-in-bed treatment should be contin- 
ued as long as the child has fever and marked throat symptoms. In every 
case the physician should carefully examine the heart in anticipation of 
the possible development of acute endocarditis, and frequent urinalyses 
should be made, as albuminuria may occur. 

Medical. — The medical treatment consists in giving quinin, sodium 
salicylate, aspirin, phenacetin, or salol. Quinin is a valuable remedy and 
should be given to all children who are old enough to take pills or capsules. 
In younger children, and especially in infants, quinin, because of its 
taste, is contraindicated. The struggle to give an infant quinin in liquid 
form may not only produce great nervous excitement, but may upset its 
stomach and cause it to refuse food and other medication. Salicylate of 
soda from oil of wintergreen is a valuable remedy in older children. It 
may be given in capsule combined with the quinin, or in solution put up 
with glycerin and peppermint water. For a child from six to ten years 
of age, two grains of quinin and three grains of salicylate of soda may be 
given every four to six hours. In younger children aspirin is a valuable 
remedy; it may be given, combined with sugar, in one-grain powders to 
a child two years of age; this dose may be repeated at three-hour inter- 
vals. One grain of phenacetin, one or two grains of salol, and one grain 
of sugar may be given as a powder to infants between the ages of one and 
two. This prescription is effective in protecting the gastrointestinal 
canal, reducing the temperature, relieving the nervous irritability, and 
making the infant altogether more comfortable. The above remedies are 
to be used during the acute stage of the disease, which lasts but two or 
three days ; the aspirin, and especially the sodium salicylate, may be given, 
however, for a longer time to older children in whom there is a clear family 
history of gout or rheumatism. At the very onset of the disease the infant 
or child should be given calomel in small doses until one or two grains 
have been taken. This is to be followed by a dose of castor-oil, or saline 
laxative; the castor-oil is preferable. On the third or fourth day of the 



TREATMENT OF DISEASES OF THE TOXSILS 423 

treatment a second dose of castor-oil should be given; the oil serves the 
purpose of clearing the intestinal canal and preventing gastrointestinal 
complications; the germ-laden mucus, which is swallowed, can in no 
manner be so satisfactorily carried off. The care of the intestinal canal is 
especially important in the treatment of tonsillitis in infants under two 
years of age; this applies with equal force to the treatment of all catarrhal 
conditions of the respiratory passages. Intestinal infection and gastro- 
enteritis are not only troublesome, but dangerous complications, much 
more serious than the tonsillitis which produced them. Infants, there- 
fore, suffering from tonsillitis should have their milk formulas reduced, 
and if diarrhea appears it should be treated by diet and proper 
medication. 

Local Treatment. — In the majority of instances relief and benefit 
follow the application of cold to the neck. This may be applied in the 
form of cloths wrung out of ice-water, or by a small ice-bag wrapped in 
a towel, and placed under the angle of the jaw over the tonsillar region. 
Cold applications are of special value when the lymphatics at the angle of 
the jaw are enlarged, when there is a throbbing sensation in the throat 
with marked tenderness externally over the tonsils, and in individuals 
who have had repeated attacks of quinsy; the early application of cold 
may in these cases prevent the formation of a peritonsillar abscess. In 
some cases very hot applications applied to the neck give more relief than 
cold; in younger children and infants the hot applications are, as a rule, 
preferable. Older children should gargle, or use a spray of peroxid of 
hydrogen, diluted two or three times with water; this is indicated for 
twenty-four or thirty-six hours only. It is an excellent throat antiseptic, 
but if continued too long, as Jacobi long ago pointed out, irritates the 
mucous membrane. As the white patches disappear on the second or third 
day, the peroxid of hydrogen solution is to be changed for some mild al- 
kaline antiseptic, which may also be used as a gargle, or with an atomizer, 
so as to thoroughly cleanse the throat and pharynx of the mucopurulent 
discharge which is present. These alkaline antiseptic solutions may be 
made by adding boracic acid to a physiological salt solution, or by using 
some of the alkaline antiseptic tablets now on the market. It may be 
necessary to paint the throat or use stronger or more astringent gargles 
and sprays. A weak solution of the tincture of chlorid of iron, one 
to four or five parts, may be used for painting the tonsil during conval- 
escence. Weak iodin and silver (argyrol) solutions may also be used for 
swabbing the tonsil, but on the whole these stronger applications are rare- 
ly indicated in the convalescence from acute tonsillitis. They are of more 
value in the subacute or chronic forms of tonsillar hypertrophy. 

Infants and children suffering from tonsillitis are made more com- 
fortable by sponge and tub baths, which relieve the nervousness and reduce 
the temperature. During convalescence older children are benefited by 
such tonics as fresh air, good food, and the malt and iron preparations. 
The tincture of chlorid of iron and the syrup of iodid of iron are old 



424 DISEASES OF THE PHAKYNX 

and time-honored remedies of value in these cases. They may be given 
after meals in three to five-drop doses diluted with glycerin and water. 

Treatment of Vincent's Angina. — The treatment of Vincent's angina 
consists chiefly in the careful local application of caustics to the ulcerated 
area, such as strong nitrate of silver solutions and chromic acid. 

Treatment of Peritonsillar Abscess. — Peritonsillar abscess, or quinsy, 
should be treated by opening the abscess with a guarded bistoury, and the 
throat, for a number of days following the incision, should be disinfected 
by some of the alkaline antiseptics above mentioned. 

Treatment of Chronic Tonsillar Hypertrophy. — The treatment of 
chronic tonsillar hypertrophy falls within the domain of the throat spe- 
cialist, rather than the general practitioner. The guillotine in the hands 
of an inexperienced operator may remove the greater part of the tonsils 
and give relief for a number of years, but if tonsillar tissue be left there 
will be in most instances a gradual return of the tonsillar tumor, and a 
second operation some years later may be necessary. For this reason the 
radical operation of enucleating the entire tonsil within its capsule is 
much to be preferred. Adenoids and other hypertrophied lymphoid tissues 
of the lymphoid ring of the pharynx should always be removed at the same 
time; this is a slight operation, which should follow the removal of the 
tonsils. It may be well also to note that a white, innocuous membrane, 
somewhat resembling diphtheria, forms over the wound produced by re- 
moving the tonsil. 



CHAPTEE XLVIII 
DISEASES OF THE PHARYNX 

ADENOIDS 

In 1868 Dr. William Meyer, of Copenhagen, called the attention of 
the medical world to the hypertrophy and disease of the lymphoid tissue, 
which so commonly occur in the vault and posterior and lateral walls of 
the nasopharynx. This lymphoid tissue is spoken of as Luschka's tonsil, 
or the pharyngeal tonsil, and the hypertrophy is commonly spoken of as 
adenoid growths. Other portions of the pharyngeal wall, however, no- 
tably its posterior surface, are rich in lymphoid tissue, and these lymphoid 
follicles are commonly markedly enlarged when there is any great increase 
in the size of the pharyngeal tonsil. These enlarged follicles, therefore, 
which may be readily seen on the posterior wall of the pharynx, are an 
important indication of the presence of adenoid growths. The faucial 
tonsils are also commonly diseased and hypertrophied in the presence of 
marked adenoid disease; this, however, is not always so, since extensive 
adenoid growths, almost rilling the vault of the nasopharynx, may be pres- 
ent with little or no disease of the tonsils ; this is more commonly seen un- 



ADENOIDS 425 

der three years of age. In adenoid growths the orifices of the Eustachian 
tubes are not infrequently surrounded by diseased adenoid tissue. 

Frequency. — Much difference of opinion still exists as to the frequency 
of this disease. It has been variously estimated that from 10 to 35 per 
cent, of all school children between the ages of six and ten, living in cold, 
damp climates, such as are found in our middle and northern states, have 
sufficient adenoid disease to demand operative interference. It should be 
remembered that the pharyngeal tonsil is normal tissue, and that a mod- 
erate amount of hypertrophy may exist without producing either local or 
constitutional injury. The question, therefore, for the physician to decide 
is not whether the child has adenoids, but whether the adenoids are suffi- 
ciently enlarged or diseased to produce either a local or constitutional 
disturbance which injures its health. 

Etiology. — Adenoids are especially common between the ages of four 
and ten, but they are not infrequent during the first year of life and may 
be congenital. Heredity, the lymphatic diathesis, glandular tuberculosis, 
and cold, damp climates are classed among the predisposing causes, but 
the real cause of the disease is infection. The adenoid tissue becomes more 
and more hypertrophied with repeated infections, and in its folds the 
microorganisms, capable of producing acute inflammation, are held from 
one acute attack to another. All the etiological factors of rhinitis become 
the etiological factors of adenoid growths, since repeated attacks of coryza 
are almost constantly associated with hypertrophy of this lymphoid tissue. 
Colds in the head, ordinary epidemic grippe, true influenza, measles, 
and all the acute infections capable of producing catarrhal disease of the 
mucous membrane of the nose and pharynx may be etiologically related to 
adenoid growths. 

Symptomatology. — The symptoms vary greatly with the extent of the 
hypertrophy of the lymphoid tissue, with the severity of the inflammation, 
and with the associated complications. The most characteristic symptoms 
are recurring attacks of rhinitis, tonsillitis, pharyngitis, and laryngitis, 
with snoring and mouth breathing in the intervals between these attacks. 
Sleeping and waking, the child's mouth is partially open; this is due to 
partial nasal obstruction. The voice is thick, muffled, and frequently has 
a nasal twang. Earache and partial deafness are common. Otitis media 
may occur. An unexplained running of the ear, which fails to yield to 
ordinary treatment and which is associated with recurring attacks of 
pharyngitis, is almost always due to adenoid growths. Recurring attacks 
of epistaxis are not infrequent. Laryngitis and bronchitis very frequently 
follow the acute pharyngitis, which is from time to time lighted up by 
chronic adenoid disease. The nervous symptoms associated with adenoid 
disease vary greatly. In aggravated cases the child may suffer from sleep- 
lessness, general nervous irritability 7 , headache, night -terrors, and incon- 
tinence of urine. There can be no question but that pronounced adenoid 
growths, occurring in malnourished and neurotic children, may produce 
very pronounced reflex neuroses. In such cases I have frequently seen 



426 DISEASES OF THE PHAEYNX 

night-terrors and incontinence of urine disappear when the adenoids were 
removed. An enlarged chain of lymph nodes behind the sternocleidomastoid 
muscle, when associated with the catarrhal symptoms above described, is 
strongly confirmatory of adenoid growths. In marked cases of adenoid 
disease which have existed for a long time, the facial expression of the 
child may strongly suggest the condition. He has a stupid, vacant look, 
his mouth is open, the bridge of his nose is flat, his upper lip appears 
thick, the nasolabial fold is obliterated, and his lower jaw protrudes in 
such a manner as to give the appearance of a long face which narrows 
toward the chin. The hard palate may show a very high arch and the 
upper teeth may be displaced. Not infrequently these children have nar- 
row, poorly developed chests, and are below par in their physical devel- 
opment. They also have the appearance of being below normal in their 
mental development; this, however, is perhaps largely due to their stupid 
expression and to the fact that because of partial deafness, or their fre- 
quent attacks of illness, they have not had mental training in keeping 
with their age. The mental deficiency in these cases is not real, but 
merely apparent, and disappears quickly with the removal of the adenoids 
and the improvement of the child's general physical condition. In young 
infants the nasal occlusion caused by adenoid disease interferes with nurs- 
ing. As the infant sleeps, its mouth and pharynx become dry, and it 
not infrequently awakens with a choking cry and for a time may have 
difficulty in getting its breath. These symptoms are more commonly 
due to the associated rhinitis than to the adenoid disease. 

Diagnosis. — The diagnosis of adenoids may be suspected or even made 
from the above symptom group, but the extent of the disease and fre- 
quently its existence can only be definitely determined by digital ex- 
amination of the nasopharynx. For this examination the physician stands 
behind the patient and holds the child's head firmly with his left arm; 
the finger of his right hand is quickly introduced back of the soft palate, 
high up into the nasopharynx ; there the location, the extent, and the char- 
acter of the adenoid mass may be felt. The adenoid tissue is usually soft 
and friable; the examining finger therefore comes away bloody. In. 
other instances, small, hard adenoid masses are located, which do not 
break down readily. During this examination, which requires but a few 
seconds, the child's mouth is to be held open with a mouth-gag, or with 
the fingers of the left hand, pushing in the cheek between the molar teeth, 
otherwise the finger of the right hand, which is making the examination, 
may be bitten or otherwise injured. 

Treatment. — The medical treatment of acute adenoid inflammation 
is in every way similar to the treatment of rhinitis, which has been already 
given in detail. The treatment of acute catarrhal inflammations of the 
tonsils, larynx, and bronchial tubes, which are frequently associated with 
adenoid disease, is given in the treatment of these conditions. There is 
in fact no medical treatment which has more than a palliative influence. 
The treatment of adenoid growths is essentially surgical, and when 



KETKOPHAKYNGEAL ABSCESS 



427 



operative interference is necessary these cases should be referred to a 
specialist. The removal of these growths is not a difficult operation, but is 
one requiring a certain 
amount of experience 
and skill, and this is 
especially true since 
very commonly in con- 
nection with the re- 
moval of adenoids it is 
advisable to remove the 
tonsils. In very young- 
children it is better to 
remove the adenoid tis- 
sue alone unless the 
tonsils be markedly hy- 
pertrophied and dis- 
eased. This can be done 
without an anesthetic. 
Indications for 
Surgical Treatment. 
—Adenoids should be 
removed in all cases 
where either by local ir- 
ritation or general con- 
stitutional disturbance 
they interfere with the 
health of the child; 

when the middle ear has been involved; when associated with recurring 
attacks of rhinitis and tonsillitis; when pronounced neurotic disorders are 
present, and when the nasal obstruction is such as to produce mouth breath- 
ing. In addition to this, large adenoid growths filling the vault of the naso- 
pharynx should be removed whether or not they produce local or other 
symptoms. 

RETROPHARYNGEAL ABSCESS 

The comparative frequency of this condition in infancy is due to the 
abundant distribution and marked functional activity of lymph nodes and 
their connecting vessels in the pharyngeal wall at this age. The dimin- 
ishing frequency after the second year of life is believed to be due to the 
gradual disappearance and diminished functional activity of the lym- 
phatics in the posterior and lateral walls of the pharynx during early 
childhood. Infection of these lymph nodes, and the consequent develop- 
ment of a retropharyngeal abscess, occurs more readily because of the 
close communication of the pharyngeal lymphatics with those of the naso- 
pharynx. The pus-forming cocci and the influenza bacillus are the common 




Fig. 67. — Position 



in Examination 
Growths. 



for Adenoid 



428 



DISEASES OF THE PHARYNX 



exciting causes. Koplik found streptococci in all of his cases. Infection 
is commonly secondary to ulcerative or catarrhal inflammation of some 
part of the throat or nasopharynx; adenoid inflammation, tonsillitis, or 
pharyngitis usually precede the retropharyngeal abscess. Influenza, scarlet 
fever, diphtheria, and the various acute infections which produce ca- 
tarrhal disease of the respiratory passages may be exciting causes. Gland- 
ular tuberculosis, rickets, and other constitutional diseases, which pro- 
duce malnutrition, may be predisposing factors. Age is the most notable 
predisposing cause. Bokay records 467 cases of which 296 occurred during 
the first year of life, and thereafter the disease occurred with gradually 
diminishing frequency, being very rare after the fifth year. These statis- 
tics, which are in accord with those of Koplik and other observers, show 
the comparative infrequency of this disease after the first year of life. 

Symptomatology. — The symptoms are frequently obscured in the be- 
ginning by the causative infection. As these subside the characteristic 
syndrome produced by a retropharyngeal abscess begins to make its ap- 
pearance. The type of temperature changes and becomes septic in char- 
acter, with marked remissions and perhaps intermissions. The obstruction 

caused by the swelling 
in the pharyngeal wall 
causes the infant to re- 
ject its food; it lets go 
both the breast and the 
nipple to get its breath. 
When asleep the infant 
snores, and may awaken 
with marked difficulty 
in breathing, in bad 
6EAl cases gasping for air. 
Not infrequently a 
hoarse cough is an ag- 

Fig. 68.— Retropharyngeal Abscess. (Poirier and Charpy.) g ravatm g symptom, but 

it has not the barking, 
characteristic hoarse sound of either spasmodic or true croup. The pharyn- 
geal stridor continues when the child is awake. The head usually is held 
rigidly and often inclined toward one side, and the infant cries when the 
neck is bent from this position. The lymph nodes at the angle of the jaw 
are enlarged. 

The above clinical picture can scarcely be mistaken for anything ex- 
cept laryngeal stenosis, and there should really be no difficulty in making 
the diagnosis between these two conditions. The fluctuating temperature 
and the absence of the characteristic croupy cough should exclude both 
spasmodic and true croup. Finally an examination of the pharynx of the 
child reveals the tense fluctuating tumor on the postero-lateral pharyngeal 
wall ; this tumor, from one-half to one inch in diameter, may sometimes 
be seen by using a tongue depressor, or it may be felt by gently introducing 




INTERRUPTING 

NODULE 

NODE or 

DEEP CERVICAL 

CHAIN 

EFFERENT 

VESSEL OF 

RETROPHARV 

NODES 



ACUTE LAEYNGITIS 429 

the finger and exploring the posterior pharyngeal wall. Great care should 
be exercised in making this examination not to rupture the abscess pre- 
maturely. 

Prognosis. — When the disease is discovered early, and properly treated, 
there is little danger to life; nearly all such cases promptly recover. If 
the abscess burrows and finally ruptures spontaneously the child may be 
suffocated by the pus. 

Treatment .—There should be no delay in opening the abscess after 
it has been discovered. In making this operation, care should be exercised 
to prevent the contents of the abscess from passing into the larynx. The 
child should be placed on its back and its head allowed to hang over the 
edge of the table (Eose position) and a mouth-gag introduced. With 
the index finger of one hand as a guide, a pointed hemostatic forceps, with 
the blades closed, should be forced into the abscess cavity and then the 
blades separated until the pus has been evacuated. The child's head 
should be securely held until the danger of aspirating the pus is over. 
General anesthesia is to be avoided (Iglauer). To prevent refilling of the 
abscess it is sometimes necessary to introduce a probe or finger into the 
opening once a day for two or three days following the operation. In 
rare instances the deeper lymphatics are involved and the abscess points 
not only into the pharynx, but also into the neck. In such cases the ab- 
scess cavity should be opened externally. This operation, however, is more 
difficult and should be done by a surgeon. Following the opening of such 
an abscess externally, it should be drained and given proper surgical 
treatment, until it gradually heals from within outward. 



CHAPTEE XLIX 

DISEASES OF LAEYNX 

ACUTE LARYNGITIS 

This is an acute catarrhal inflammation of the larynx, which, in infants 
and young children, is commonly associated with spasm of the glottis. For 
this reason it is popularly spoken of as false croup, spasmodic croup, or 
catarrhal croup. 

Etiology.- — Laryngitis may occur as a primary infection, but, as a rule, 
it is secondary to catarrhal processes of the throat or nasopharynx. 
Ehinitis, more or less severe, is its most common antecedent. Laryngitis 
may also be a part of the symptom group in measles, influenza and whoop- 
ing-cough. Cases associated with measles are not infrequently very violent 
in character. The pathogenic microorganisms capable of producing acute 
laryngitis are very frequently found on the normal mucous membranes 
of the throat and nose, and long exposure to damp, cold, or raw winds 
may cause a congestion of these mucous surfaces, and thus make it possible 



430 . DISEASES OF LARYNX ' 

for these microorganisms to incite a laryngitis. Laryngitis is much more 
common in the young child; when it does occur in older children the 
spasmodic element, which is partly responsible for the laryngeal stenosis, 
is absent, and the disease runs a comparatively mild course without alarm- 
ing symptoms. The spasmodic form of this disease, called "false croup/' 
occurs most frequently between the end of the first and the fifth year of 
life. It may occur even during the first year, and in neurotic children, 
who have been subject to croup, it may occur after the sixth year. One 
attack predisposes to another. There may also be a family predisposition 
to this disease. It is especially common in malnourished, neurotic children. 
The hereditary factor in many cases may be a nervous one. Eickets, 
chronic glandular tuberculosis, chronic anemia, and mouth breathing are 
important predisposing factors. Acute laryngitis not only occurs more 
commonly in highly nervous, malnourished children, but, in this type of 
child, the spasmodic element is much more severe and the attack of croup 
is therefore much more alarming. 

The pathological condition causing this symptom group is the con- 
gested, swollen, and inflamed subglottic mucous membrane of the larynx, 
covered with' more or less mucus. This greatly interferes with the free 
passage of air through the larynx and produces an inspiratory dyspnea. 
When to this is added spasm of the glottis, the laryngeal stenosis may 
for a time be almost or quite complete. 

Symptomatology. — Catarrhal laryngitis, as it occurs in the older child, 
unassociated with spasm of the glottis, may be a primary or secondary 
process. It is commonly preceded by rhinitis, pharyngitis, or tonsillitis, 
or associated with influenza or measles. The fever, which is almost con- 
stantly present in these cases, is in no way characteristic, and adds little 
to the diagnosis of the disease. It is usually slight and variable, ranging 
from normal to 101° or 102° F. ; in severe cases it may reach 
104° F. High fever not infrequently depends upon the associated disease, 
such as influenza. The cough, dyspnea, and hoarseness are more or less 
characteristic symptoms. The cough is harsh and croupy in character; the 
most pronounced croupiness usually occurs at the onset, or at least early 
in the disease, and gradually disappears, leaving a laryngeal, tracheal, or 
bronchial cough which lasts for a week or ten days. The cough is the 
most persistent symptom ; it may be paroxysmal, almost incessant, or nag- 
ging in character. The voice is hoarse, and, in some instances, almost lost, 
but the hoarseness, like the cough, is an early symptom which gradually 
subsides. Dyspnea is a more or less marked symptom, but is not so prom- 
inent in older children; the difficulty in breathing when it exists is as- 
sociated with an inspiratory stridor. All of the above symptoms are more 
aggravated at night. Such is the clinical picture presented by laryngitis 
in the older child, and it diifers little from that seen in the adult, except 
that perhaps in the child the cough is more croupy and associated with 
more dyspnea. 

The clinical picture, however, produced by false croup in the young 



ACUTE LARYNGITIS 431 

child is very different from the one just described. There are few 
clinical syndromes which cause more widespread alarm in a household than 
an attack of spasmodic croup. The young child may go to bed without 
premonitory symptoms, but usually there is some slight warning during the 
day or late afternoon in the form of a slightly hoarse cough, which may 
or may not be associated with coryza or pharyngitis. The child, however, 
does not appear to be very ill and his temperature is but slightly above 
normal. He falls asleep as usual and, commonly before midnight, awakens 
with a harsh, croupy cough, which can be heard even in adjoining rooms. 
It is accompanied by great difficulty in breathing, an inspiratory stridor 
and very pronounced hoarseness. The difficulty in breathing increases, 
the face becomes cyanosed, and the child is apparently threatened with 
immediate suffocation. If the attack be a severe one, the mother and 
other attendants are thrown into a state of anxiety bordering on panic; 
this excites and alarms the child and perhaps aggravates the attack. The 
dyspnea in these cases is so pronounced that all the accessory muscles of 
inspiration are brought into play; there are wide flaring of the nostrils 
and a deep sinking in at the suprasternal notch and diaphragmatic groove. 
Attacks of such severity commonly last from a few minutes to one-half 
hour. Great difficulty in breathing, however, may continue for hours. As 
the attack subsides the child's breathing becomes less harsh and less la- 
bored, and it falls back more or less exhausted upon the bed and sleeps 
until morning. Following the attack, its clothing is wet with perspira- 
tion. In rare instances more than one attack may $ccur during a night. 
The following morning the child is found with perhaps little or no fever; 
it is bright, feels well and desires to get out of bed as usual. The bark- 
ing cough, the dyspnea, and the hoarseness have all largely disappeared. 
There may be some inspiratory stridor.; whistling rales may be heard in 
the large bronchi; hoarseness may still be present to a slight degree; the 
cough, which has lost its hoarse, metallic character, still persists, and 
throughout the day it is a prominent and irritating symptom. If the child 
is allowed to go about, and especially if it is not properly treated, the 
cough, dyspnea, and hoarseness gradually increase as bed-time approaches, 
and the child falls asleep and has another attack, perhaps near the same 
hour as the first night; it is, however, usually less severe. The second 
day the child again appears convalescent, but on the third night another 
and milder attack may occur. These croupy attacks do not usually recur 
for more than three nights in succession and their severity will depend 
upon the treatment instituted, as well as upon the physical condition 
of the patient; nervous, malnourished children are more subject to severe 
and recurring attacks. The fever may continue for three or four days 
and the cough usually lasts for a week or ten days. After the second or 
third day it gradually becomes tracheal and bronchial in character, the 
croupiness, hoarseness, and dyspnea being no longer present. 

Diagnosis. — Catarrhal croup must be differentiated from laryngeal 
diphtheria. This, as a rule, is not difficult; there is no preliminary his- 
29 



432 DISEASES OF LAEYNX 

tory of sore throat, no membrane is present on the tonsils or pharynx, 
and the onset of the disease is sudden. The greatest dyspnea, the hoarsest 
cough, and the most marked aphonia occur during the first night, and all 
of these symptoms almost disappear the next morning, possibly to recur 
the next night or two, diminishing in violence. This is in marked contrast 
with the gradual onset of diphtheritic laryngitis, in which the dyspnea, 
hoarseness, and croupiness come on slowly and gradually, from two to 
three days being required to produce a dangerous laryngeal stenosis; the 
inspiratory stridor continues during the day, although the whole symptom 
group may be more aggravated at night. In clearly defined cases the 
differential diagnosis is simple, but now and again we may have a primary 
laryngeal diphtheria which can scarcely be differentiated from ordinary 
acute laryngitis, and occasionally we may have very severe attacks of 
acute laryngitis, in which the symptoms, more or less modified, persist 
during the following day and recur with marked severity the following 
night. In such cases it may be absolutely impossible to make a differential 
diagnosis, therefore the child should be given a large dose of antitoxin 
(see Diphtheria), and careful bacteriological cultures from the larynx 
made to determine the presence or absence of the Klebs-Loffler bacillus. 
The diphtheria antitoxin in these cases should be given as a diagnostic 
measure, without awaiting the results of a bacteriological examination. 
A laryngoscopic examination may reveal the presence of a membrane in 
doubtful cases. 

Prognosis. — The prognosis is good. Fatal cases, however, have been 
recorded. Bronchitis, which is the common and usual complication, pro- 
longs the cough and other symptoms. Pneumonia, which is a com- 
paratively rare complication, may terminate fatally. 

Treatment. — If the child is seen for the first time during the severe 
spasmodic attack an emetic is indicated; teaspoonful doses of syrup of 
ipecac may be given every half hour until vomiting is produced ; as a rule, 
only one dose is necessary. The emetic clears out the pharyngeal and 
perhaps some of the laryngeal mucus, but, more important than this, it 
relieves the laryngeal spasm, and thus controls the severe dyspnea in a 
short time. Following the emetic, the child's stomach should be allowed 
to rest, undisturbed by medicine or food; some hours later liquid food 
and the following prescription may be given: 

Potassium bromid grs. 60 

Antipyrin grs. 15 

Glycerin 3 \ 

Elixir of lactated pepsin ad § ii 

Sig. A teaspoonful every three hours to a child two or three years of age. 

The bromid of potash and antipyrin in the above prescription are to 
be increased or diminished to suit the age of the child. In children over 
three years of age one drachm of syrup of ipecac may take the place of 
the glycerin in this prescription. This remedy is to be given every three 



ACUTE LARYNGITIS 433 

hours the first day, every four or five hours the second day, and thereafter 
one dose at bed-time for four or five days. This will almost always pre- 
vent second and third attacks, and will also, in the great majority of 
instances, prevent the first attack, if the preliminary symptoms give suf- 
ficient warning to permit the giving of several doses of this remedy during 
the preliminary hoarseness, which sometimes precedes these attacks. 
Mothers having croupy children should be provided with this mixture 
and advised to give it with the onset of any catarrhal condition of the 
throat or nose, especially if it be associated with the slightest hoarseness. 
In severe cases, where the emetic does not act promptly, or where it fails 
to give relief, a few inhalations of chloroform may be given to relieve 
the spasm of the glottis. This is indicated only where cyanosis is marked 
and difficulty of breathing, almost to the point of suffocation, is present. 
In some instances the laryngeal stenosis may be so great, and the diagnosis 
between acute laryngitis and laryngeal diphtheria so ill defined, that intuba- 
tion and a good-sized dose of diphtheria antitoxin may be advisable. In 
ordinary laryngitis these remedies can do no harm and in diphtheritic 
laryngeal stenosis they are life-saving measures. If the bacteriological 
examination and the subsequent clinical history show the case to be one of 
true diphtheria of the larynx, much valuable time will have been saved, 
and the patient's chances for life will be much better by having given the 
antitoxin. 

The child should be kept in bed on the day following the attack and 
perhaps as long as the fever and croupy cough are present. It is also al- 
most universally recommended that children suffering from laryngitis 
should breathe warm, moist air. Croup tents of various kinds are used 
for this purpose. The bed is so tented that steam from a croup-kettle, or 
some other steam generator, can be directed into it. By this device the 
child is made to breathe warm air heavily laden with moisture. Tincture 
of benzoin, turpentine and guaiacol may be added to the water from which 
the steam is made. These drugs, when inhaled, are believed to have a 
soothing and antiseptic effect. While the croup tent may be of value, my 
own experience is that it does very little good. I have not used it in the 
past five years in the treatment of any kind of croup. These children do 
better in rooms having a temperature of about 70° F., well ventilated with 
fresh, comparatively warm air, carrying a moderate amount of moisture. 
Warm applications to the neck in the form of hot fomentations or hot 
poultices are of value in relieving the spasm of the initial attack as well 
as in preventing second and third attacks. Warm baths have a soothing 
and relaxing effect. During convalescence, syrup of hydriodic acid, syrup 
of the iodid of iron, cod-liver oil, and other tonics are of value. 

The treatment of so-called croupy children during the interval between 
attacks is most important. They should avoid, if possible, all contagion 
and exposure to damp cold; should be warmly clad during the cold, damp 
months of winter; should live in the fresh air during the day and sleep 
in it during the night; they should be built up by careful feeding, regular 



434 DISEASES OF LAEYNX 

diet, and suitable tonics, such as cod-liver oil, malt, and iron, and, if 
they have a chronic tonsillar hypertrophy, or adenoid growths, these should 
be removed. 

EDEMA OF THE LARYNX 

Edema of the larynx, incorrectly called edema of the glottis, is an 
edematous swelling of the submucous cellular tissues of the larynx and the 
aryepiglottic folds. This edema may be a simple serous infiltration, due 
to causes remote from the larynx, not associated with acute inflammation; 
in such cases the edematous mucous membrane may be pale or slightly 
congested. But in the most common group of cases it is secondary to an 
acute submucous inflammation of the larynx; in this form the exudate is 
seropurulent in character, and the mucous membrane of the larynx is 
red, swollen, ulcerated, and sometimes lacerated. 

Etiology. — The simple serous infiltration from constitutional causes is 
comparatively rare in the child; it may be produced by acute and chronic 
nephritis, cardiac insufficiency, and by lymph nodes, and other tumors, 
the pressure of which prevents normal circulation in the larynx. The 
inflammatory form is due to infection and subsequent inflammation, or to 
foreign bodies in the larynx, or injuries of the mucous membrane, pro- 
duced by the swallowing of corrosive chemicals or the inhalation of 
steam or irritating vapors. It also occurs as a rare complication of syphilis, 
smallpox, chickenpox, scarlet fever, diphtheria, measles, and other infec- 
tions, which may excite inflammation of the laryngeal mucous membrane. 

Symptomatology. — The most important symptom group is that pro- 
duced by the laryngeal stenosis. An inspiratory dyspnea, which, in se- 
vere cases, threatens or even takes the life of the child by suffocation, is 
the important symptom. The child struggles for breath, is cyanotic, all 
the accessory muscles of inspiration are brought into play, orthopnea, 
laryngeal stridor, and aphonia are present. In the inflammatory cases 
the child complains of pain in the region of the larynx. The suddenness 
of the onset of the above symptom group largely depends on the exciting 
cause ; following severe traumas it is more rapid in its development. As a 
rule, the diagnosis may be confirmed by introducing the finger so as to 
come in contact with the edematous aryepiglottic folds, or by using the 
laryngeal mirror or the direct laryngoscope to bring the edematous tissues 
into view. 

Prognosis. — The prognosis will depend largely upon the exciting cause, 
and ofttimes upon the promptness with which the symptoms are relieved 
by surgical or other measures. Untreated cases very frequently terminate 
by suffocation. The milder types of the disease, due to constitutional 
causes, usually yield to the proper medical treatment of the exciting cause. 

Treatment.- — If marked cyanosis is present and the child, is threatened 
with suffocation immediate intubation should be resorted to. In an in- 
stance that came under my observation about fifteen years ago a suffo- 



FOREIGN BODIES 435 

eating edema of the larynx was produced by a small foreign body. When 
the tube was introduced the child was blue and seemed almost moribund, 
but, immediately following the introduction of the tube, the child com- 
menced to breathe, and within one-half hour all evidences of cyanosis 
had disappeared. In this instance the foreign body, which was the hook 
of an ordinary hook and eye, was pushed into the trachea, where it re- 
mained for six weeks, producing a most irritating cough and more or 
less bronchitis. It was finally coughed up and the child had a rapid 
recovery. In some instances it may be necessary to perform tracheotomy 
and allow the tube to remain in the trachea until the edema of the larynx 
has disappeared. Scarification of the edematous tissue in some instances 
gives relief. All of these operative measures, however, should be carried 
out, if possible, by a specialist. The medical treatment of the localized 
inflammation in the larynx is the same as that previously recommended 
for ordinary laryngitis. Where heart disease and acute nephritis are 
the exciting causes these conditions must receive treatment. Hot baths, 
diaphoretics, and saline laxatives are indicated in nephritis. Digitalis, 
absolute rest, and a dry diet, containing not more than a pint and a half 
of liquid in twenty-four hours, are indicated in heart disease. 

NEOPLASMS IN THE LARYNX 

This is a comparatively rare condition and is essentially a surgical one. 
Of laryngeal tumors, papillomata are the most common. Fibromata and 
malignant growths also occur. 

The diagnosis in these cases is made by the slow onset of an inspiratory 
dyspnea, commonly associated with increasing hoarseness, and sometimes 
with an increasing cough. A laryngoscopic examination reveals the pres- 
ence of the tumor. These cases should always be referred to the spe- 
cialist for surgical treatment. The relief following the removal of papil- 
loma of the larynx is pronounced and immediate, but frequently after 
some months the return of the growth is announced by the slow return 
of the symptoms of laryngeal stenosis, and second and third operations 
may be necessary. The long-continued use of Fowler's solution is said to 
prevent recurrence after operation. 

FOREIGN BODIES IN THE LARYNX, TRACHEA AND IN 

THE BRONCHI 

Foreign bodies in their passage to the bronchi not infrequently lodge 
for a time in the larynx, producing violent irritation of this organ, 
sometimes resulting in edema of the larynx, but in most instances, after 
a violent fit of coughing and strangling with more or less dyspnea, they 
are either dislodged outwardly from the larynx, or pass into the trachea, 
where they cause more or less irritation. 

All kinds of small foreign bodies may find their way into the trachea 



436 



DISEASES OF LABYNX 



and small bronchial tubes. Particles of food, buttons, coins, grains of corn, 
pebbles, and all the small objects with which children commonly play, may 
be aspirated into the trachea and bronchi. As previously noted, in their 
passage through the larynx they may excite symptoms of acute laryngeal 
stenosis, but after passing into the trachea and bronchi there is great 
variation in the symptoms they produce. As a rule, cough of a paroxysmal 




Fig. 



69. — Marked Dilatation of the Right Lung, Produced by Foreign Body 
in the Right Bronchus. (Iglauer.) 



and aggravated type is a prominent symptom, and a whistling bronchitis 
of the larger tubes is nearly always present. I recently saw a case produced 
by the kernel of a peanut in the right bronchial tube. This child was two 
years of age and had been treated for some months for asthma. Its breath- 
ing was labored, and large sibilant rales could be heard over both lungs. 
The respiratory movements on the left side were more marked than on 
the right, and the vesicular murmur was markedly diminished on the right. 
These physical signs, in the absence of dullness, indicated plainly that 



43: 

the air was passing into the left lung much more readily than into the 
right, and the diagnosis of a foreign body in the right bronchus was 
made. The X-ray picture here presented failed to reveal the presence 
of the foreign body, and also for a time added confusion to the clinical 
picture by showing that the right lung was distended and contained more 
air than the left. The foreign body, which was afterwards located and 
removed from the right bronchus, acted as a valve, which impeded ex- 
piration more than inspiration. In most of these cases, however, the re- 
verse of this is true, and the X-ray picture may show the lung fed by the 
obstructed bronchus to contain less air than the other. In many instances 
also the foreign body is of such a character that it can be located by an 
X-ray picture. Increased respiratory movements on one side and di- 
minished vesicular murmur on the other, occurring in a young child 
which has a troublesome cough and whistling bronchitis without fever or 
the physical signs of pneumonia, should be sufficient to suggest the diag- 
nosis of an obstructed bronchus. In addition to this, there is usually a 
history of an acute attack of strangling with acute laryngeal irritation, as 
the result of "swallowing some foreign body the wrong way." In some 
instances these foreign bodies may remain for months or years without 
seriously interfering with the health of the child, and then again, after a 
long period of quiescence, they may produce hemoptysis, or a circumscribed 
bronchopneumonia. The ultimate diagnosis is made by the specialist, 
who locates the foreign body by the bronchoscope. In the use of this in- 
strument it is sometimes necessary to make a preliminary tracheotomy. 
This is especially true of the infant, in whom it is frequently impossible 
or impracticable to use the bronchoscope through the larynx. 

Prognosis. — Under proper treatment the prognosis is usually good. In 
the hands of a specialist, skilled in the use of the proper instruments, 
foreign bodies, even though they be well down in the bronchial tubes, can 
be rather readily removed. The prognosis in untreated cases is usually 
very bad. The foreign bodies in time may produce a fatal inflammation 
of the pulmonary tissues. 

CONGENITAL LARYNGEAL STRIDOR 

This is a rare congenital condition, the etiology of which is unknown. 
The infantile character of the larynx persists, and the epiglottis is turned 
back, so that the lateral edges come in contact, leaving a very narrow 
opening between the aryepiglottic folds, producing a valve-like condition 
which obstructs the intake of air. 

Symptomatology. — The stridor is purely inspiratory and, according to 
Thomson, consists of a loud crackling or croaking sound on inspiration, 
accompanied by the physical signs of an inspiratory dyspnea. Expiration, 
on the other hand, is easy and noiseless, and cyanosis, as a rule, is not 
marked. The stridor varies greatly in its intensity, and may at times 
entirely disappear and then again recur under nervous excitement, or 



438 BRONCHITIS 

catarrhal conditions of the larynx. The paroxysms of dyspnea, as a rule, 
increase in severity during the first six months of life and then gradually 
subside, to disappear before the end of the second year. 

This condition may be differentiated from laryngismus stridulus, thymic 
asthma, papilloma, and other obstructive lesions of the larynx by the 
fact that it begins at or immediately after birth and by the characteristic 
syndromes of the above-named conditions. 

Treatment. — The child should be protected from nervous excitement 
and should be carefully guarded from all contagions which may produce 
catarrhal conditions of the nasopharynx. Fresh air, careful feeding, and 
all measures which will improve the physical condition of the infant will 
modify the severity of the paroxysms and shorten the course of the disease. 
The prognosis in uncomplicated cases is good. 



CHAPTER L 

BEONCHITIS 

ACUTE CATARRHAL BRONCHITIS 

Bronchitis is a catarrhal inflammation of the bronchial mucous mem- 
brane which, especially in infancy, has a tendency to spread downward 
and involve the small bronchi.. 

Etiology. — Glandular tuberculosis, rickets, syphilis, anemia and chronic 
diseases of the adenoids, tonsils, pharynx, and nasal mucous membrane 
are the most important predisposing causes. 

Infection is the essential factor in the etiology of acute bronchitis. 
The most common exciting microorganisms are the staphylococcus aureus, 
the pneumococcus, the streptococcus, the influenza bacillus, and the bacil- 
lus catarrhalis, but it may be produced by typhoid, diphtheria, and tubercle 
bacilli, and it is commonly associated with epidemic grippe, measles, per- 
tussis, and scarlet fever. The influenza bacillus is commonly responsible 
for the chronic form of bronchitis. 

The great majority of these cases occur during the winter or spring 
months. This is partly because the contagions which produce bronchitis 
are rife at this time, but also because this is the season when children are 
huddled together in close, ill-ventilated rooms, not only at school but in 
their homes. They are thereby forced to breathe an impure, germ-laden 
air, which is the direct cause of bronchitis. If the laity could get away 
from the bugbear that "catching cold" is the all-important cause of this 
disease and learn that the way to avoid bronchitis is to live and sleep in the 
open air, the morbidity and mortality from this disease would be enor- 
mously decreased. I do not wish to convey the impression that prolonged 
exposure to damp cold can do no harm ; on the contrary, it is an important 
exciting cause of bronchitis. This factor, however, can only excite bron- 



ACUTE CATAEEHAL BEONCHITIS 439 

chitis in children who carry upon their respiratory mucous membranes 
one or other of the microorganisms which may cause this disease. I 
do not believe it is wise to expose the legs or other portions of the body 
to damp cold, with the idea that it exercises a hardening influence upon 
the child and prevents disease. It is not desirable that the skin of the 
child should be hardened, but only that it should breathe fresh air. During 
the winter months, in order that this may be accomplished with safety, it 
is not only wise but advisable that the child should be properly clothed 
so that all portions of his body may be comfortably warm. 

Age is an important predisposing factor. Bronchitis is most com- 
mon between the sixth month and the end of the third year of life. 
After this time it rapidly decreases in frequency. 

Pathology. — The mucous membrane of the trachea and bronchi is con- 
gested and swollen, its blood vessels dilated, and its secreting structures, 
especially the mucous cells, increased in size and activity. The mucosa 
and submucosa are infiltrated with small, round cells, and with the bac- 
teria producing the disease. The bronchi contain more or less mucus or 
a mucopurulent exudate. The peribronchial tissues are not involved. 

Symptomatology. — Fever and cough announce the onset of simple bron- 
chitis. There is nothing characteristic in the fever. It rises gradually 
to 102° or 104° F., is irregular in character, runs a short course, and 
usually reaches normal in from four to seven days. It runs an afebrile 
course in very young infants, and even in older ones, suffering from gastro- 
intestinal disease, rickets, or other malnutritions. In those cases asso- 
ciated with influenza and other acute infections the high fever seen in 
the beginning is due to the general toxemia. As this subsides, the lower 
and irregular temperature of bronchitis may continue for a number of 
days before it reaches normal. If the fever remains high and prolonged, 
it is an evidence of a beginning bronchopneumonia, otitis media, or some 
other complication. The cough is the most prominent and the most 
troublesome symptom. It is always present, except in very young and 
feeble infants, and directs attention to the lungs as the site of the disease. 
In the beginning it is usually dry, irritating and unproductive; at this 
time the child is not seen to swallow following the cough. Later it is 
loose, less paroxysmal, and less troublesome, and usually gives more or 
less relief as it brings up into the pharynx some of the mucus which the 
child is seen to swallow following the cough paroxysm. In some instances 
the cough is associated with pain and more rarely with vomiting. Children 
under six or seven years of age do not usually expectorate; it is therefore 
difficult to obtain specimens of sputum for examination. If this is thought 
necessary, however, the sputum may be obtained by wiping out the pharynx 
with a gauze-wrapped finger or a cotton-wrapped probe. In this way it 
may be possible to decide whether the disease is produced by pneumococci, 
influenza bacilli, streptococci, or other microorganisms. Such information 
is of little or no value from a therapeutic standpoint, and this procedure 
therefore is hardly justifiable as a routine method of differential diagnosis. 



440 BRONCHITIS 

The respiratory movements are more rapid than normal, and perhaps 
slightly labored. In simple bronchitis, in children over six months of age, 
there is practically no evidence of dyspnea ; when, in such a case, therefore, 
the wings of the nose begin to flare, and the peripneumonic groove begins 
to recede with each inspiration, it is time for the physician to employ 
his most potent remedies to prevent the onset of bronchopneumonia. It 
should be remembered that there is also a form of afebrile asthmatic bron- 
chitis, presenting all the evidences of increased labor on the part of the 
accessory muscles of inspiration, such as dilatation of the alse nasi, sinking 
in of the suprasternal notch, and inspiratory recession of the walls of 
the chest in which, notwithstanding these symptoms, there is little or no 
danger of bronchopneumonia. This form may commonly be differentiated 
from ordinary bronchitis by the inspiratory stridor, the sibilant rales, and 
by the fact that the child has little or no fever. In very young and deli- 
cate infants there is even in simple bronchitis a slight amount of dyspnea 
with flaring of the nostrils and a slight recession of the peripneumonic 
groove. 

Physical Signs. — The physical signs are well marked and by them 
the diagnosis of bronchitis is made. In almost every case bronchial fremi- 
tus may be felt. The vibrations of the chest wall are very significant 
to the experienced touch. The early sibilant and whistling rales, and the 
subsequent mucous rales, which may be heard in both the large and 
medium-size bronchi, give unmistakable evidence of this disease. Fine 
crepitant rales, which may occur at any time during the progress of a 
bronchitis, mean the onset of pneumonia. Inspection may reveal rapid 
breathing and a slight inspiratory retraction of the chest wall. This is 
especially true in young and delicate children, but when these signs are 
exaggerated they may be an indication of a beginning bronchopneumonia. 
Percussion is of comparatively little value except for determining when 
the disease is passing from the stage of bronchitis to that of pneumonia. 

The course of simple bronchitis is usually from four to eight days; the 
disease, however, may be prolonged with intermissions for a period of 
from four to five weeks; this is common in those cases associated with 
subacute or chronic disease of the adenoids and tonsils. Reinfection may 
cause relapses in hospitals and even in private homes which are not 
properly ventilated and disinfected during and following an epidemic of 
bronchitis. 

Complications. — Otitis media, mastoiditis, bronchopneumonia, intes- 
tinal toxemia, and gastroenteritis are common and dangerous complica- 
tions. 

Prognosis. — The prognosis is, on the whole, good, but during the early 
weeks of life it should be guarded, since at this time the disease may run 
an insidious course with little or no fever, few constitutional symptoms, 
and but slight cough, and vet, during all of this time, well-marked physical 
signs of bronchitis may be present, and a fatal bronchopneumonia may 
develop before the physician is aware that the infant is seriously ill. 



ACUTE CATARRHAL BRONCHITIS 441 

Prophylaxis. — Every rhinitis, pharyngitis, or slight catarrh of the 
tracheal or bronchial mucous membranes should have prompt and careful 
treatment; this especially applies to the new-born and to syphilitic, rachi- 
tic, and other malnourished infants. Breathing pure air, living out of 
doors during the day, sleeping with open windows at night, and wearing, 
during the cold winter months, clothing that will keep the skin and body 
warm and dry are important prophylactic measures. All contagion should 
be avoided. Well infants should be kept away from persons suffering from 
ordinary colds, tonsillitis, grippe, and other acute infections. In children 
in whom the disease recurs from time to time, or who have a tendency 
to subacute nasopharyngeal catarrh, the throat and nose should be in- 
spected and all diseased tissues removed. 

Treatment. — The infant or child with acute bronchitis should, if pos- 
sible, be confined to bed in a large, bright, isolated room, the windows of 
which are opened wide enough to let in plenty of fresh air. Care should 
be taken that the atmosphere of the room be not dried out with artificial 
heat ; a moist, pure air is soothing to the irritated bronchial mucous mem- 
branes. As a rule, all that is necessary is to admit the outside air; this 
generally secures sufficient moisture. Where this cannot be satisfactorily 
accomplished, the air of the room may be moistened by heating water in 
an open vessel. The infant or child should be clothed so that its body 
will be kept warm whatever may be the temperature of the room. In 
winter the bedroom should be kept between 60° and 70° F. 

The medical treatment is largely symptomatic. In the beginning, if 
the child be suffering from some acute intoxication, such as influenza, 
which produces high fever and marked discomfort, phenacetin may be 
given for one or two days but should not be continued longer. A safe 
prescription in these cases is guaiacol carbonate, 1 grain; salol, 1 grain, 
and sugar, 1 grain. This dose may be given every three or four hours 
to an infant under one year of age, and may be increased to suit the 
age of the child. The cough may be allayed by the use of bromid of 
potash, 45 grains; tincture of belladonna, 15 minims; glycerin, 2 drachms, 
and elixir of lactated pepsin, enough to make 2 ounces. A teaspoonful of 
this mixture may be given every three hours to an infant one year of 
age. For older children, syrup of ipecac, 1 drachm to the ounce, may 
be added to this prescription, and the doses of the other ingredients 
increased to suit the age of the child. The opium preparations are almost 
never indicated in children under two years of age, but for sturdy children, 
over this age, 1 to 2 drachms of camphorated tincture of opium may be 
added to the above prescription. In the chapter on Bronchopneumonia 
I have spoken most decidedly concerning the danger of giving opium, 
cough syrups, ammonium carbonate, ammonium muriate, tartar emetic, 
squills, and ipecac, and what is said there applies with almost equal force 
to their use in ordinary bronchitis. These remedies are rarely indicated, 
and I feel quite sure that more harm than good is done by their in- 
discriminate use in children under two years of age. 



442 LOBAR PNEUMONIA 

In beginning the treatment, the gastrointestinal canal is to he thor- 
oughly unloaded by a dose of castor oil. and throughout the disease this 
dose is to be repeated every three or four days to prevent intestinal in- 
fection by the mucus and pus which have been coughed up and swal- 
lowed. Warm tub baths or warm sponge baths are very grateful, and serve 
a useful purpose in the treatment of bronchitis. They quiet the nervous 
system, promote the action of the skin, and act as a general tonic. Cold 
baths and cold packs are not indicated; this is especially true in infants 
under eighteen months of age. Antipyretics are not needed to reduce the 
temperature. Inunctions of guaiacol. 1 drachm to the ounce of anhydrous 
lanolin, should, in one-half-teaspoonful doses, be thoroughly rubbed into 
the skin of the chest, night and morning. A light oilskin jacket, lined with 
a thin layer of cotton-wool, is of value, and is especially indicated in the 
infant and young child during the cold winter months when the fresh-air 
treatment is being given. If at any time the symptoms indicate that a 
broncho-pneumonia may be developing, flaxseed poultices are to be used as 
directed in the chapter on Bronchopneumonia. 

CHRONIC BRONCHITIS 

Chronic bronchitis is comparatively rare in children. The only form 
that here need be mentioned is the asthmatic bronchitis previously re- 
ferred to. Its treatment may require carbonate of creosote, syrup of 
hydriodic acid, cod-liver oil, malt, and other tonics. A warm, equable 
climate is of value. 

MEMBRANOUS BRONCHITIS 

In this condition the mucous membrane of the trachea and bronchial 
tubes is covered with a fibrinous deposit. It is comparatively rarely seen, 
except in diphtheria, where the diphtheritic membrane may extend down 
into the bronchial tree. It also occurs occasionally in croupous pneumonia 
and some of the other acute infections. The symptoms are those of a 
severe bronchitis, and the diagnosis is made on the expulsion of fibrinous 
casts. 

The treatment is that of severe bronchitis in addition to the specific 
disease which produces it. 



CHAPTER LI 

LOBAE PNEUMONIA 

(Croupous Pneumonia, Fibrinous Pneumonia) 

Etiology. — This is an inflammation of the lungs which, in from 90 
to 95 per cent, of the cases, is caused by the Frankel diplococcns pneu- 
moniae (pneumococcus). It is believed that in the majority of these cases 



PATHOLOGY 443 

there is a general infection with the pneumococcus, and that the pul- 
monary lesion is but a local expression of a general constitutional disease. 
From this viewpoint we may class the disease among the acute infections. 
The lungs are the favorite site for the local lesion, because the pneumo= 
coccus commonly finds its entrance through these organs, and also per- 
haps because they are especially susceptible to pneumococcic inflamma- 
tions. Clinical experience, as well as pathological and bacteriological re- 
search, has taught us that it is better to consider this disease from the 
broad viewpoint of a general infection, and as such we shall speak of it 
in this chapter. It should be remembered, however, that the same croupous 
or fibrinous lesions found in lobar pneumonia may perhaps, in a very 
small percentage of cases, be produced by organisms (Friedlander's bacillus, 
Pfeiffer's bacillus, and streptococci) other than pneumococci; at least it 
may be said that pneumococci have not been found in these cases, and again, 
on the other hand, it should be noted that the pneumococcus, in its on- 
slaught upon the lungs, is associated in its destructive processes with strep- 
tococci, staphylococci, the Friedlander bacillus, and other organisms which 
so commonly produce secondary infections. 

Exposure to damp cold, the inhalation of irritating particles, and 
all causes that produce congestion or catarrhal inflammation of the respi- 
ratory passages may be important predisposing causes in that these con- 
ditions incapacitate the mucous membranes for resisting the pneumococcus. 
Influenza, measles, and other acute infections may act in the same way. 
Croupous pneumonia is comparatively rare during the first six months of 
life, but is very common from that time to the end of the second year, 
and is comparatively frequent up to the fifth year. It is more common 
during the winter and spring, and occurs with equal frequency in robust 
and feeble children. 

Pathology. — The most important pathological condition is the pneu- 
mococcic septicemia. The pneumococcus may be demonstrated in the blood 
in most of these cases, and it is found in the pulmonary lesions in nearly 
all cases that come to post-mortem examination. In fatal cases it is com- 
monly associated with streptococci, staphylococci, or other organisms. 
The pulmonary lesions do not occur so early and are not so frank 
and apparent as in the adult. But the pulmonary lesion, when it does 
occur, is similar to that of the adult and therefore requires no detailed 
description here. The pulmonary inflammation in lobar pneumonia be- 
gins in the lung tissue and not in the small bronchi as in bronchopneumonia. 
It spreads more or less rapidly through the lung by continuity of sur- 
face, usually confining itself to one lobe. A fibrinous exudate is thrown 
out, which, with the other inflammatory products, results in an airless 
or consolidated condition of the part of the lung affected. The inflam- 
matory lesion passes through the stages of congestion, red and gray hepati- 
zation and resolution. The pleura in nearly every case is more or less 
involved, usually so slightly, however, as not to affect the course or 
prognosis of the disease. The pleurisy may be fibrinous, serous or purulent 



444 LOBAK PNEUMONIA 

(empyema). When empyema occurs this complication becomes the dom- 
inant symptom group, greatly exceeding in importance and danger the 
original condition. 

The whole or part of one lobe may be involved, or, less commonly, 
more than one lobe in the same or in different kings may be affected. Very 
rarely an entire lung may be consolidated. The central area of a lobe may 
be involved for some time before the disease reaches the surface and pro- 
duces physical signs. It is probable, however, that most of these so-called 
"central" pneumonias are cases of general pneumococcic infection in which 
the pulmonary lesion appears as a late manifestation. The pulmonary 
lesion occurs with about equal frequency in the right upper and left lower 
lobes; in about two-thirds of the cases the disease begins in one or the 
other of these sites. The left upper and right lower lobes are affected 
with about equal frequency, the disease occurring in these locations about 
half as frequently as it does in the right upper and left lower lobes. Much 
less commonly, the right middle lobe is the first part of the lung to be 
affected. The statistics of different writers vary somewhat with reference 
to the frequency of the involvement of the right upper and the left lower 
lobes ; in infants the right upper lobe is more frequently involved, in chil- 
dren the left lower lobe is the favorite site. 

Symptomatology. — General Symptoms. — Within a few hours the child 
presents the appearance of being acutely ill ; it is feverish, dull, listless, and 
gives little heed to its surroundings. In older children a distinct rigor, 
followed by a sudden elevation of temperature and pain in the side, may 
call attention to the lungs as the site of the disease, and soon these symp- 
toms may be followed by cough, and later by rusty sputum and the physi- 
cal signs of acute lobar pneumonia. We are here interested, however, more 
especially with the symptoms of this disease as it appears in the infant and 
young child, in whom the early symptom-complex is very different. The 
chill is rarely present; a convulsion may occasionally take its place, or, 
with the sudden rise in temperature, the child may feel chilly, have 
cold extremities, and its face show a pinched expression. With the sudden 
onset of acute symptoms, the evidences of a severe acute intoxication are 
well marked; there is high fever and the infant is dull, stupid, more or 
less prostrate, and is little, if at all, interested in its food or toys ; anorexia, 
to the extent of absolutely refusing food, is common, but thirst is in- 
creased. Cough and pain in the side are not usually present during the 
first days of the disease. Vomiting is an early and common symptom 
but does not, as a rule, persist after the second day. Diarrhea is rather 
common in infanc}^ but constipation is more frequent in older children. 
Associated with the high fever, which may reach 104° or 105° F. in the 
first twenty-four hours, there is a rapid increase of frequency in both the 
respiration and pulse, but marked dyspnea, with flaring of the nostrils 
and retraction of the lower part of the chest, is not, as it is in broncho- 
pneumonia, an early and prominent symptom. The normal ratio be- 
tween the pulse and respiration is disturbed; this is a very valuable early 






SYMPTOMATOLOGY 



445 



symptom. The respiration commonly ranges from 50 to 70, and the pulse 
from 140 to 160; the respiration-pulse ratio is thereby increased from 
the normal 1 to 4, to 1 to 2y 2 or 3; later in the disease this ratio may 
be as 1 to 2. On the second or third day there is more or less cough, 
and the characteristic expiratory grunt may be associated with slight 
dyspnea, which tends to confirm the diagnosis and stimulate the physician 
to a careful search of the chest for the earliest physical signs associated 
with the pulmonary lesion. The fever continues high for from five to 
eight days, and is perhaps during this time more sustained than in any 
other disease of early childhood. As the physical signs in many cases 
appear late, the diagnosis must be made or at least suspected by the general 



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Fig. 70. — Lobar Pneumonia; Child Two Years of Age. 



symptom-complex as above outlined. The sudden onset, with high and 
sustained fever, the marked constitutional depression with listlessness and 
sometimes stupor, the disturbance in the pulse-respiration ratio, the cough, 
the slight dyspnea, and the expiratory grunt are usually sufficient to make 
a tentative diagnosis of pneumonia. 

Fever. — In the great majority of cases the temperature rises suddenly 
so that within the first twenty-four or thirty-six hours it may reach 105° 
or 106° F. It continues high, fluctuating slightly, until the crisis occurs 
on or about the seventh day. At this time it is not unusual for the tem- 
perature to fall within twelve or twenty-four hours from 105° F. to below 
normal, and with this fall there is a rapid decrease in the pulse and 
respiration. This subnormal temperature may continue for a day or two. 



446 



LOBAE PNEUMONIA 



or it may be varied by slight elevations before it becomes normal. An 
uninterrupted recovery commonly follows. In not every case, however, 
is this typical temperature curve observed, irregularities of various kinds 
being possible. In a minority of cases the fever falls by lysis with sharp 
variations in the temperature until it . finally reaches normal. Abortive 
cases occur in which the fever may continue high for two or three days, and 
then suddenly fall to normal. In other instances the fever may be pro- 
longed, with irregularities, or even short intervening normal periods, for 
two or three days; these cases are sometimes spoken of as relapsing pneu- 
monias. They represent those cases in which there is an extension of the 
pneumonic process to other parts of the lung after the focus of primary 
pulmonary inflammation has almost or quite run its course. 



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Fig. 71. — Lobar Pneumonia; Child Four Years of Age. 

Respiration. — This, as previously noted, is accelerated out of propor- 
tion to the increase in the pulse rate. It commonly varies between 40 and 
80 ; the younger the infant the more rapid the respiration. The tachypnea 
or rapid breathing, however, in this disease is associated with comparatively 
little dyspnea, and in this it differs markedly from bronchopneumonia. 
In some cases, however, as the disease progresses, the accessory muscles of 
respiration are brought into play and flaring of the nostrils is noted, but 
the marked drawing in of the chest at the diaphragmatic groove, which is 
so characteristic of bronchopneumonia, is slight or not at all present. 
The pause, however, which occurs at the end of inspiration, followed by 
shallow expiration, and associated with an expiratory grunt, is very char- 
acteristic of lobar pneumonia. 



SYMPTOMATOLOGY 



447 



Cough. — During the first day or two cough may he entirely absent, 
but sooner or later it becomes a noticeable symptom, not infrequently as- 
sociated with pain in the side or abdomen. The cough is one of the last 
symptoms to disappear and is not infrequently more pronounced during 
convalescence than during the height of the fever. Sputum is difficult 
to obtain, as young children do not expectorate. Occasionally, however, 
specimens may be secured when the child vomits, or cough may be ex- 
cited by introducing a gauze-wrapped finger into the pharynx, and wiping 
up the sputum as it is brought up in this way. Sputum thus obtained 
may present the typical rusty appearance, and pneumococci in great num- 
bers may be demonstrated in it. 



DAY 
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Fig. 72. — Lobar Pneumonia; Child Ten Years of Age. 

The Blood. — Blood cultures will, in the great majority of cases, 
demonstrate the presence of the pneumococcus, but this procedure is not 
necessary or justifiable for routine diagnosis. A well-marked polynuclear 
leukocytosis is present, which may reach from 40,000 to 50,000 to the 
cubic m. m. A high leukocyte count is a favorable indication, while a 
low leukocyte count, with well-marked physical signs of lobar pneumonia, 
is an unfavorable sign. 

Urine. — The urine, in many of these cases, contains a trace of albumin 
with occasional hyalin and granular casts. This febrile or toxic albuminuria 
is of comparatively little significance as it disappears shortly after the 
crisis. Acute nephritis may occur as a rare complication. 

Physical Signs. — In examining the chest of infants and young chil- 
dren the physician must keep in mind the fact that the inspiratory sounds 
30 



448 LOBAR PXEUMOXIA 

at this period of life are loud and coarse in quality, and that this is es- 
pecially noticeable on the right side, beneath the clavicle and over the 
spine of the scapula. This normal puerile breathing may easily be mis- 
taken for bronchial or tubular breathing, such as is found in pneumonia. 
The physical signs of pneumonia in infancy are similar to those occurring 
in the adult, but they not infrequently appear so late that they are of 
little value in the early diagnosis of this disease, and, in some instances, 
they may never be discovered or they may be so evanescent as to be 
misleading. These facts, however, only make it more imperative that the 
physician should carefully search the chest, day after day, in all suspected 
cases. 

Percussion. — It is important to remember that light percussion may 
disclose small areas of dullness where strong percussion fails. In the 
early diagnosis of croupous pneumonia, however, percussion is little to 
be relied upon, but as consolidated areas appear they may be discovered, 
and in advanced cases the dullness may be well marked over one or more 
lobes of the lungs. 

Auscultation. — Auscultation is of great value. By it one may sooner or 
later discover crepitant and subcrepitant rales, the most valuable of all 
physical signs. These are commonly heard at the base or apex of the lungs ; 
sometimes they are first heard in the axillary region; the whole lung 
should, day after day, be carefully searched for them. Bronchophony is 
an early and valuable physical sign, and bronchial breathing may later 
be made out over the consolidated lung. Coughing, and crying, by pro- 
ducing deep inspirations, may serve to bring out or make the auscultatory 
signs more pronounced. 

Complications. — Pleurisy is the most common complication. In most 
instances it adds to the discomfort rather than to the seriousness of the 
disease. In a small minority of the cases, however, instead of a simple 
fibrinous or mild serous pleurisy, we have a complicating empyema, which 
at once becomes the most serious feature of the disease. In every instance, 
where delayed convalescence is associated with an intermittent fever, em- 
pyema should be suspected and carefully searched for. Otitis media is 
a common complication. Meningitis is a rare complication, but meningism 
is not uncommon. Arthritis, peritonitis, pericarditis, endocarditis, osteomy- 
elitis, abscess of the liver, and diseases of the accessory sinuses of the nose 
are possible complications, all of which may be excited by the pneumo- 
coccus. Bronchopneumonia is a common and very dangerous complica- 
tion in children under two years of age, but it is more often seen in hos- 
pital than in private practice. Pneumonia occurring in tuberculous chil- 
dren may be prolonged and may develop into an active, advancing 
pulmonary tuberculosis. 

Splanchnic, or vasomotor, paralysis, as Eomberg and Passler have 
shown, may result from the action of pneumococcus toxins on the vaso- 
motor center. In this condition the blood is withdrawn from the heart 
and the general circulation into the dilated veins of the splanchnic area, 






TEEATMEXT ±±9 

and the heart, because of the scarcity of blood, becomes feeble and ir- 
regular in action, and death may result. This condition occurs only 
when there is a profound general pneumococcus infection. 

Differential Diagnosis. — In some cases vomiting, slight intestinal dis- 
turbance, fever, and general toxemia may suggest a gastrointestinal in- 
toxication, but since a laxative with abstinence from food makes little 
or no impression upon the fever and constitutional symptoms, intestinal 
toxemia may thereby be quickly eliminated. In some cases the vomiting, 
the stupor, the delirium, the rigidity of the muscles of the neck and upper 
part of the back, to which may be added a certain degree of opisthotonos, 
very strongly suggest meningitis. These symptoms, however, come on 
slowly, so that by the time the meningeal syndrome is closely simulated 
one can, as a rule, find the physical signs of pneumonia in the lungs. In 
other cases the vomiting, abdominal pain and distention, tenderness, and 
slight resistance on the right side over the head of the colon may strongly 
suggest appendicitis ; many such cases have been operated upon. The well- 
known tendency of the child to refer thoracic pain to the abdomen makes 
the danger of mistaking a pneumonia for an appendicitis more probable. 
Griffith says: "The distinction is to be made by giving due consideration 
to (1) the sudden rise of temperature to 103° F. or thereabouts, and the 
tendency to maintain this degree; (2) the acceleration of respiration, which 
is out of proportion to the pulse rate or pyrexia; (3) the relaxation of 
the abdominal walls between the respirations; (4) the diminution or the 
disappearance of tenderness on deep pressure with the flat of the hand; 
(5) the possible presence of cough. Finally no operation for appendicitis 
should ever be performed until after a careful or perhaps repeated ex- 
amination of the lungs has been made." For the further differential 
diagnosis see Bronchopneumonia. 

Prognosis. — The prognosis in uncomplicated lobar pneumonia in the 
infant and young child is vastly better than it is in the adult. The great 
majority of these cases get well, and there is perhaps no serious disease 
of infancy and childhood in which the convalescence is so rapid and so 
satisfactory. Following the crisis the child improves so rapidly that it 
is difficult to keep him in bed for the seven to ten days necessary to in- 
sure satisfactory convalescence. The younger the infant the more un- 
favorable the prognosis, so that in infants under one year of age, es- 
pecially where there is well-marked consolidation of the lung with high 
fever and rapid respirations, it is well to give a guarded prognosis, since 
a considerable percentage of these cases end fatally. In general terms 
it may be said that in infancy the death rate is from 10 to 20 per cent., 
and in children from 3 to 6 per cent. ; the lower figures in each case 
refer to children treated under favorable hygienic conditions in their own 
homes. 

Treatment. — It should be remembered that lobar pneumonia is a self- 
limited disease for which we have no specific and in which we may do great 
harm by over-medication. The treatment must be largely hygienic and 



450 LOBAR PNEUMONIA 

sustaining, and even the symptomatic treatment which is indicated at 
every stage must not be overdone. 

Hygienic Treatment. — The hygiene of the sick room is all-important. 
The child should be put to bed in a large, bright room, under the care of 
a trained nurse, instructed to keep the room quiet and free from unneces- 
sary visitors. The most important agent is fresh air. This fact was long 
ago emphasized by Northrup, who has continued for the past ten years to 
be the most ardent advocate of the fresh air treatment not only of pneu- 
monia, but of many other acute diseases; as he says, the air in the room 
"should be fresh, cool, and flowing." In other words, the patient is to be 
in a room with windows open night and day, even though the temper- 
ature in the room, during the winter months, falls as low as 60 °F. ; with 
proper indoor heating apparatus the room may be kept at a temperature of 
60° to 65 °F., with fresh, cool, "flowing air" coming in through two or 
more windows. In carrying out this treatment it is evident that not only 
the garments, but the bed-clothing, of the child should be adapted to the 
temperature of the room. The body of the child must be kept com- 
fortably warm, while it is breathing the fresh, cool air. If necessary, hot 
water bottles and warm blankets should be used on very cold days. The 
nurse on duty in such a room should dress to protect herself from the 
cold. When this treatment was coming into vogue, a number of years 
ago, the physician found it difficult to overcome the prejudice against 
"catching cold," but the success of the outdoor or fresh air treatment of 
this disease has been so clearly demonstrated in the last ten years that 
the laity have now come to accept it without protest. 

Dietetic Treatment. — The importance of the dietetic treatment is 
emphasized by the fact that gastric and intestinal disturbances are com- 
mon, and that anorexia is often so pronounced, that the child refuses all 
food; in the face of these conditions the physician is called upon to com- 
bat, with proper food and nourishment, an exhausting disease, which may 
run for a week or more with high fever, and severe toxic symptoms. In- 
fants and young children can usually be induced to take a moderate amount 
of liquid foods, such as modified milk, beef juice, meat broths and egg 
albumin ; it is important, however, that these foods should not be given at 
such short intervals, and in such quantities, that the weakened digestive 
capacity of the infant will be overtaxed, and intestinal fermentation with 
gaseous distention be thereby produced. In underfed infants whiskey or 
brandy is indicated from the beginning of the disease. In my experience, 
good rye whiskey acts better than brandy ; when mixed with water and 
a little sugar it is readily taken, and produces no gastrointestinal disturb- 
ance; where the carbohydrate intake is small whiskey acts as a food 
rather than as a stimulant, and thereby furnishes energy to the cells and 
prevents emaciation and loss of strength. It is my custom to give to 
infants, between one and two years of age, 20 or 30 drops three or four 
times in the twenty-four hours; this dose may be increased with increas- 
ing toxemia and prostration. 



TREATMENT 451 

Cool water to drink and plenty of it was long ago recommended in 
the treatment of pneumonia. While these children have little or no ap- 
petite, they are thirsty, and will drink a large quantity of cool water, 
the intake of which helps to reduce the fever and to diminish the toxemia, 
as it promotes the excretion of toxins through the skin and kidneys. 

Local Applications. — Poultices and oil silk jackets encasing the 
chest are not indicated in this form of pneumonia. Hot water bottles, 
electric pads, small poultices and mustard plasters may be used for the 
relief of the pleuritic pain, when it is severe enough to interfere with sleep. 
Mustard plasters, which are so universally recommended as counter- 
irritants, should be strong enough to produce only redness of the skin 
without blistering; two parts of flour and one part of mustard made into 
a paste and spread between two layers of gauze may be used for this pur- 
pose. I have rarely found it necessary to use counter-irritation in the 
treatment of lobar pneumonia in children. Priessnitz's applications are 
of great value when the fever is high and the respirations rapid. They 
are applied by dipping a piece of light flannel in water (temperature 
about 70°F.), wringing it out, applying it to the entire chest of the child, 
and covering it with a dry flannel. The wet flannel may be changed from 
every half hour to three hours, as the symptoms demand. 

Antipyretics. — It is most important that the physician should not 
center his attention upon the high temperature and attempt to beat it 
clown with cold water and other antipyretics. A temperature of 103^2° 
or 104° F. in lobar pneumonia, as a rule, does not require antipyretics; 
hyperpyrexias of 105° and 106 °F., however, demand treatment. The use 
of baths for the reduction of temperature will depend altogether upon the 
manner in which the individual case responds to this treatment. If the 
high temperature is associated with marked nervous symptoms and other 
evidences of profound toxemia, hydrotherapy will, in the great majority 
of cases, give great relief, not only by reducing the temperature, but also 
by quieting the nervous symptoms and stimulating nutritional processes. 
If such a favorable result follows the use of the bath, it may be used as 
indicated throughout the course of the disease. Many cases suffering from 
nervous symptoms and severe toxemia are benefited by a hot tub bath twice 
in twenty-four hours, but when these symptoms are associated with high 
temperatures sponging with alcohol and water, or what is much more 
effective, the cold pack, may be resorted to three or four times in twenty- 
four hours. In giving the cold pack, the body of the child should be 
wrapped in a bath towel wrung out of cold water, and over this a light 
dry blanket should be wrapped. The towel may be removed after one- 
half hour and the child sponged off with alcohol and warm water. Ice- 
caps may be applied to the head with benefit, especially in those cases with 
high temperature and pronounced nervous symptoms. 

The coal-tar antipyretics are almost universally condemned by writers 
upon this subject, and yet they are almost universally used by the general 
practitioner, and I am inclined to believe, from my own experience, that 



452 LOBAE PXEITMONTA 

in certain cases of high temperature with pronounced nervous symptoms 
phenacetin may be used to advantage, especially in older children. There 
is no question as to the sedative and antipyretic action of this drug. It 
will ofttimes produce a quiet sleep by relieving headache and other pain, 
and I am of the belief that the sleep thus produced does more good than 
the depressing effect of the phenacetin can do harm. Under two years of 
age this drug should not be used, but in older children it is to be recom- 
mended, not as an antipyretic, but occasionally to relieve the pain, rest- 
lessness and nervousness, which prevent sleep. 

Medical Teeatment. — With the onset a cathartic should be given. 
Castor oil is to be preferred, if nausea and vomiting do not prohibit its 
use; if castor oil is contraindicated, calomel should be given, followed by 
a dose of Eochelle salts. Throughout the course of the disease the gastro- 
intestinal tract should be carefully watched and cathartic medication re- 
sorted to, to prevent abdominal distention, to overcome constipation, and 
to clear the canal of fermenting food stuffs, which may be adding an 
intestinal toxemia to the existing disease; this is especially important in 
infants and young children. Care should be exercised that this laxative 
treatment be resorted to only when necessary, as harm may result from 
unnecessary catharsis. 

Quinin is a remedy of value in the routine treatment of pneumonia 
in children over two years of age. It should be given in the form of 
euquinin to young children, and in the form of the sulphate or bisulphate 
.to older ones. The disagreeable taste of this drug is a rather serious ob- 
jection to its administration in a disease in which so much depends upon 
the giving of proper foods and stimulants, and its greatest value, there- 
fore, is in children who are old enough to take it in capsule form. The 
vaccine treatment is contraindicated in acute forms of pneumonia. In 
the chronic forms, however, which are occasionally seen in older children, 
an autogenous vaccine, or the pneumococcus stock vaccine, may be used at 
times with great advantage as directed under vaccine therapy. The use 
of antitoxic serums has not been followed by appreciably good results. 
Carbonate of guaiacol or creosote may be given internally, but their value 
when administered in this way is so problematical that it is much better 
to administer guaiacol by inunction. One drachm of liquid guaiacol when 
thoroughly incorporated with 1 ounce of anhydrous lanolin may, as a 
routine me'asure, be administered night and morning, by inunction in 
y 2 - or 1-drachm doses, as recommended in the chapter on Therapeutics of 
Infancy and Childhood. 

Tincture of strophanthus is, in my opinion, the most valuable stim- 
ulant we have in this disease. I have used it as a matter of routine treat- 
ment in every case of pneumonia which I have seen in the last fifteen 
years. I do not believe that it is contraindicated in the beginning, or that 
it should be given only when cardiac failure commences. To infants 
between one and two years of age one drop should be given every four 
to six hours; between three and four years, two drops. As the disease ad- 



TREATMENT 453 

vances, this dose may be doubled in frequency rather than in size, so that 
a child of two years, as it approaches the crisis, will be taking two drops 
every two or three hours. In severe cases, where the toxemia is great and 
the respirations rapid, sulphate of strychnin is a valuable respiratory stim- 
ulant and general tonic; for a child two years of age 1/150 of a grain 
may be given with whiskey at three- or four-hour intervals, or 1/300 of a 
grain may be given hypodermically at six-hour intervals. Caffein-sodium- 
benzoate or salicylate (in 1-grain doses by mouth, or %-grain doses hypo- 
dermically, for a child four years of age) is one of the most valuable cir- 
culatory stimulants. It is indicated in severe general pneumococcic tox- 
emia, in which there is danger of vasomotor paralysis. It should always 
be used if the pulse becomes feeble and intermittent. 

Oxygen is a valuable respiratory stimulant, but the indications for its 
use have been greatly diminished by the fresh-air treatment of this disease ; 
it may, however, be used in tiding desperate cases over the crisis; it is 
indicated when the respirations are very rapid and cyanosis is marked. 
Nitroglycerin is also recommended in threatened collapse ; 1/300 of a grain 
may be given hypodermically to a child three years of age. As previously 
noted, whiskey in large doses, 1 or 2 drachms, may be used as a stim- 
ulant and to counteract the toxemia in severe cases. 

Sedatives other than the bromids and belladonna have no place in 
the treatment of pneumonia in infancy. For children between the age of 
one and two years, three or four grains of bromid of potash and one 
minim of tincture of belladonna may be given at three- or four-hour in- 
tervals, to allay the cough and nervousness. These drugs should be given 
in some palatable vehicle, such as the elixir of lactated pepsin, so as not 
to irritate the child or disturb the stomach. Opiates are, in my opinion, 
dangerous drugs in the treatment of the pneumonias of infancy. They 
are rarely, if ever, indicated under two years of age. In older children, 
between three and five, codein, 1/10 of a grain, paregoric, fifteen or twenty 
drops, or some of the other preparations of opium may occasionally be 
indicated to relieve the pain caused by the cough or by a complicating 
pleurisy. 

Expectorants, such as ammonia, ipecac and squill preparations, are con- 
traindicated, since by disturbing the gastrointestinal tract they do more 
harm than good. 

Treatment of Convalescence. — The only treatment commonly neces- 
sary during convalescence is to keep the child in bed for a week and let 
him have plenty of fresh air and a carefully selected nutritious diet within 
the range of his digestive capacity. If, however, the child does not rapidly 
regain its strength, is anemic, and has little appetite, it may be benefited by 
such tonics as malt and iron, malt and cod-liver oil, syrup of the iodid 
of iron, or syrup of hydriodic acid. In weak children and those predisposed 
to tuberculosis, creosote or the benzoate or carbonate of guaiacol may be 
given with advantage. 



454 BRONCHOPNEUMONIA 

CHAPTER LII 
BEONCHOPNEUMONIA 

Bronchopneumonia, next to gastroenteritis, is the most common of the 
serious disorders of infancy. It is a disseminated and lobular inflammation 
of the lungs, which usually follows and is always associated with a bron- 
chitis of the smaller bronchi. It is, in the vast majority of cases, a direct 
sequel of some form of bronchitis. The many causes of bronchitis are, 
therefore, its more or less direct etiological factors. It is a syndrome rather 
than a distinct disease, in which the pathological processes are excited 
and kept up by a variety of microorganisms. The pneumococcus, which, as 
has been previously noted, is almost the sole cause of lobar pneumonia, is 
the exciting cause of bronchopneumonia in a considerable number of cases. 
The so-called primary cases of bronchopneumonia occurring in infants, are 
almost all due to this organism, and should properly be classified with the 
lobar pneumonias under the term pneumococcic infection. There are many 
difficulties, however, in adopting such a classification in a text-book. The 
various forms of pneumonia have for generations been classified according 
to their anatomical findings, and, while the terms lobar and bronchopneu- 
monia may be confusing, and actually misleading, in the light of the 
present-day conception of these diseases, they are sanctioned by long usage 
and cannot, in the present state of our knowledge, be replaced by a prac- 
tical etiological (bacteriological) classification, although the present trend 
of bacteriological research indicates that such a classification may be 
adopted in the future. It is better, therefore, from the standpoint of the 
clinician, to continue to use the terms lobar and bronchopneumonia. It 
is to be understood that lobar pneumonia is used in the broad sense pre- 
viously described, and that the term bronchopneumonia is used to mean an 
inflammatory process of the lobules and of the smaller bronchi, from what- 
soever cause this inflammation may be produced. This gives the clinician 
an opportunity to still further classify his bronchopneumonias, not only 
with reference to the age and physical condition of the child, but also 
with reference to certain more or less definite etiological factors which 
produce variations in the clinical types of this disease. 

Etiology. — Age is an important predisposing factor. Bronchopneu- 
monia is comparatively rare during the first few months of life ; it is most 
prevalent during the second six months, and continues to be very common 
during the second year; thereafter it occurs with rapidly decreasing fre- 
quency up to the sixth year. About three-fourths of the cases occur dur- 
ing the winter and spring months. This is due to the fact that the acute 
infectious diseases and bronchitis are more prevalent at this time. Bad 
hygienic surroundings are very potent etiological factors. This disease is 
found very much more frequently in hospitals, institutions for children, 
and tenement houses than it is in the homes of the well-to-do. Gastro- 



PATHOLOGY 455 

intestinal disorders, glandular tuberculosis and all forms of malnutrition, 
especially rickets, may predispose to bronchitis, and at the same time dim- 
inish the natural powers of resistance of the infant, so that a bronchitis 
may readily develop into a pneumonia. Bronchopneumonia usually fol- 
lows a simple bronchitis or a bronchitis produced by measles, influenza, 
pertussis, diphtheria, scarlet fever, or some other acute infection. The 
bronchopneumonia of measles occurs, as a rule, during the stage of erup- 
tion, but is not infrequently overlooked until the eruption has subsided. 
Bronchopneumonia occurs as a complication of whooping-cough during the 
height of that disease, when the paroxysms are severe and the resistance 
of the child is somewhat reduced by the long siege of coughing. It is 
more likely to occur in young and delicate infants, especially in those who 
are suffering from a glandular tuberculosis; it is more dangerous than 
the bronchopneumonia following measles. Influenzal bronchopneumonia 
may be due to the influenza bacillus, unassisted by other microorganisms; 
as the disease progresses, however, secondary infection usually occurs. 
True influenzal bronchopneumonia is comparatively rare, but may occur 
during an epidemic of this disease; it is more prevalent in older children 
than in infants. The bronchopneumonia following diphtheria and scarlet 
fever is usually severe; it is usually a fatal complication when it occurs 
in cases of laryngeal diphtheria, following intubation or tracheotomy. The 
most important fact to keep in mind concerning the secondary broncho- 
pneumonias caused by the acute infections is that they are nearly always 
mixed infections, and that in the vast majority of cases, especially in 
measles, pertussis, and influenza, these bronchopneumonias may be pre- 
vented by fresh air and proper hygienic surroundings, and may be produced 
by confining patients suffering from these acute infections in close, ill- 
ventilated rooms, and especially by associating them with other children 
suffering from bronchopneumonia, or any form of infection in which the 
septic cocci are causative factors. The microorganisms most commonly 
associated with the destructive processes in bronchopneumonia are strep- 
tococci, staphylococci, pneumococci, Friedlander's bacilli, influenza, tj^phoid, 
and diphtheria bacilli. 

Pathology. — The important difference between bronchopneumonia and 
lobar pneumonia consists in the primary involvement of the finer bronchi 
in the former disease, while in the latter the inflammatory process spreads 
more or less rapidly through the lung tissue without the intervention of 
a catarrhal inflammation of the finer bronchi. From this it would appear 
that in bronchopneumonia the infectious agent reaches the lung tissue 
through the small bronchi, while in lobar pneumonia it probably reaches 
the lungs through the lymph or blood channels, causing primary inflam- 
mation of lung tissue, which spreads rapidly and by extension includes the 
fine bronchi in the inflammation. This essential difference in the patho- 
logical anatomy of the two diseases would indicate that lobar pneumonia 
is really a primary acute pneumococcic infection which, as a rule, finds 
more or less extensive local expression in an acute inflammation and re- 



456 BKONCHOPNEITMONIA 

suiting consolidation of lung tissue, and which involves and is usually con- 
fined to either the whole or part of one lobe; on the other hand, broncho- 
pneumonia is always secondary to bronchitis. 

In the so-called primary cases of bronchopneumonia the infectious 
agent, which is commonly the pneumococcus, starts the process by pro- 
ducing a sudden and violent bronchitis of the smaller bronchi, instead of 
producing a bronchitis of the larger tubes, which more or less gradually 
extends downward until the finer bronchi are involved. It is a notable 
fact that of all the microorganisms which produce bronchopneumonia, 
pneumococcus is practically the only one that also produces a lobar pneu- 
monia, and it is also worthy of note that the younger the child the greater 
is the probability that a pneumococcic infection will result in broncho- 
pneumonia rather than in lobar pneumonia. 

While the inflammatory process in bronchopneumonia begins in the 
fine bronchi, it does not necessarily extend by continuity of surface to the 
associated alveoli. On the other hand, the inflammatory swelling of the 
mucous membrane commonly occludes the lumen of the small bronchial 
tubes to such an extent that we have atelectasis, or collapse of the alveoli. 
In the meantime, the microorganisms, exciting the inflammation, have 
penetrated through the small bronchi and caused inflammation of the 
peribronchial tissues and adjacent alveoli, while edematous tissue surrounds 
the collapsed alveoli above referred to. The affected lung, therefore, pre- 
sents small patches of atelectasis, emphysema and consolidation. These 
are usually widely disseminated throughout both lungs and are surrounded 
by apparently normal lung tissue. As the bronchopneumonic inflammation 
progresses the nodules increase in number and in size, and if they happen 
to be in close juxtaposition they may become confluent, producing large 
areas of consolidation, which are indistinguishable by physical signs alone 
from true lobar pneumonia. 

The nodules which hold in their embrace the affected bronchioles, 
peribronchial tissue and alveoli contain the offending microorganisms, de- 
generated epithelial cells, small round cells, leukocytes, and a mucoid 
and cellular exudate containing little fibrin. The abundant fibrinous exu- 
date which occurs in lobar pneumonia is, as a rule, an important differen- 
tiating characteristic of the inflammatory processes in the two forms of 
pneumonia; yet it must be admitted that bronchopneumonia may rarely 
produce such an extensive and circumscribed consolidation of the lung 
that it is difficult even for the pathologist to differentiate the two condi- 
tions. This confusion may arise, in some instances, from the presence at 
the same time of both forms of pneumonia in the same or in different 
lungs. 

Symptomatology. — General Symptoms. — The onset is, as a rule, grad- 
ual; there is generally a preliminary bronchitis, which grows worse, until 
a capillary bronchitis and a bronchopneumonia are produced. The transi- 
tion, however, from ordinary bronchitis to bronchopneumonia may be 
more sudden; in fact, may occur over night; yet, on the whole, except in 



SYMPTOMATOLOGY 457 

the so-called primary form of this disease, which will be considered later, 
a gradual onset preceded by a preliminary bronchitis markedly distin- 
guishes this disease from lobar pneumonia. Another distinguishing char- 
acteristic of the onset of bronchopneumonia is that the symptoms are de- 
cidedly pulmonary, pointing to a serious disease of the lungs, so that the 
physician is never misled, as in lobar pneumonia, into suspecting that 
the primary affection may be in the brain or in the abdomen. 

The disease begins with a rise in temperature, a pronounced cough and 
more or less marked dyspnea. While vomiting is rare as an initial symp- 
tom, later it is quite common. With the elevation of temperature the child 
may complain of feeling chilly, or, if too young to describe its symptoms, 
the chill may be inferred by the cold extremities and the pinched expres- 
sion about the face. The elevation of temperature, which marks the 
onset of the disease, may reach 102° or 103 °F., and this is followed by 
remissions, the temperature continuing, as a rule, to be very irregular 
throughout the course of the disease, being thus in marked contrast with 
the sustained temperature of lobar pneumonia. The cough, which was a 
symptom of the preceding bronchitis, becomes more irritable and harassing, 
and calls unmistakable attention to the lungs as the site of the disease. 
If the chest of the child be now uncovered, inspection will reveal the most 
characteristic signs of bronchopneumonia. The dyspnea, which is such a 
marked and characteristic symptom, shows itself not only by the dilata- 
tion of the wings of the nose, but more especially by the retraction of the 
lower portion of the chest, where the diaphragm is attached to the chest 
wall. This sinking in with each inspiration of the diaphragmatic or peri- 
pneumonic groove is usually very noticeable, even in the very beginning of 
the disease, and, as the disease progresses, this inspiratory retraction of 
the chest wall becomes a very pronounced and very significant symptom, 
and with it there is a sinking in of the tissues in the suprasternal region. 
These signs, which are produced by the labor of the inspiratory muscles in 
their efforts to force air into the lungs, indicate an air hunger, which is 
caused by the closing of great numbers of small bronchi and the consequent 
cutting off of the alveoli from their air supply. The younger the infant 
the more soft and flexible are the chest walls, and therefore the more 
marked are these physical signs of dyspnea, which are most characteristic 
and significant, both from the standpoint of diagnosis and prognosis. As 
the disease progresses, the infant becomes more and more prostrated, the 
distress caused by the difficulty of breathing becomes more and more mani- 
fest, expiration is accompanied by an audible grunt, the child's expression 
becomes more anxious, its features drawn, and altogether it presents the 
appearance of being critically ill. 

The pulse rate increases, varying from 150 to 200 per minute; in very 
severe cases it may be uncountable. The rapidity of the pulse, however, is 
not of so much importance as its character; if it be full and strong, its 
rapidity causes little alarm; but if it be weak, thready, intermittent, and 
compressible, it is an alarming symptom. From the beginning the respira- 



458 BKONCHOPNEUMONIA 

tions are labored and increased in frequency; they may vary from 40 to 
100 per minute, and with increasing dyspnea the infant may be unable to 
take nourishment. The prostration in these cases proceeds apace with the 
progress of other severe symptoms. Cyanosis is a much more marked and 
prominent symptom in bronchopneumonia than it is in lobar pneumonia. 
It not infrequently occurs early in the disease. A progressive cyanosis 
with coldness and blueness of the extremities is a very unfavorable sign; 
it indicates a weak circulation and insufficient oxygenation of the blood. 
If the disease gets progressively worse, all of the above symptoms become 
aggravated, the pulmonary distress is increased, inspiration becomes more 
labored, and cyanosis more marked, until the whole body has a slightly 
purplish appearance. The infant is no longer able to take food; it is dull, 
listless, and lapses into unconsciousness. The cough, which has been such 
a troublesome symptom, gradually grows less, and finally disappears, al- 
lowing the mucus to accumulate in the large bronchial tubes. Large rales 
appear in the trachea and upper bronchial tubes, the pulse becomes more 
feeble and flickering, the skin, especially of the extremities, grows cold, 
and death ensues from respiratory failure, sometimes preceded by mild 
convulsive movements. 

If the disease in bad cases terminates in recovery, the first favorable 
indication noted is that the symptom group does not grow worse. If the 
dyspnea remains at a standstill for twenty-four or thirty-six hours, a 
gradual improvement may be expected thereafter. The character of the 
breathing from day to day becomes slightly less labored, and the cyanosis 
disappears. These two indications are of the very greatest importance in 
marking the favorable turning point in bronchopneumonia. With this 
improvement the temperature curve is lower, and the general condition of 
the patient slowly improves. The child takes food better, and is again 
interested in its surroundings; the harassing cough becomes more produc- 
tive, as it more satisfactorily clears the bronchial tubes. This disease runs 
its course in from three to six weeks, and the temperature curve with its 
many irregularities gradually becomes normal. Bronchopneumonia, unlike 
lobar pneumonia, rarely terminates by crisis. 

In the above outline of the onset and general clinical history of broncho- 
pneumonia no mention is made of the physical signs elicited by percussion 
and auscultation. This is not because of their lack of importance from 
the standpoint of diagnosis, but rather because they could be better dis- 
cussed as individual symptoms. It may, however, here be noted that these 
signs are of much less value in the diagnosis of bronchopneumonia than in 
lobar pneumonia. The coarse rales of a more or less general bronchitis, 
with perhaps small scattered areas of fine crepitation, may be heard in 
nearly every case of bronchopneumonia, but, after all, the diagnosis does 
not depend upon, these findings so much as it does upon the general clinical 
picture above given. 

Individual Symptoms. — The fever of ordinary bronchopneumonia is, 
as the accompanying charts show, very irregular. It is characterized by 



SYMPTOMATOLOGY 



459 



marked remissions and sometimes intermissions, even when the tempera- 
ture is running as high as 104° or 105 °F. The remissions or intermissions 
usually occur in the morning, and the sharp exacerbations in the after- 
noon. At times the temperature may remain near the normal line for a 
number of days in succession, and then rise and again proceed on its ir- 
regular course. 

On the whole, the temperature of bronchopneumonia is of little value 
from the standpoint of prognosis. A low or even a normal temperature 
may be present in fatal cases ; this is especially true in young, malnourished 
infants. The temperature curve, therefore, of bronchopneumonia must 
be studied in connection with other symptoms. A fall of temperature, 



DAY . r | 

OF MONTH l3 ' 


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Fig. 73. — Mild Bronchopneumonia. 



when coincident with an improvement in other symptoms, is a good in- 
dication, but a fall or a slow decline, when associated with no improve- 
ment, or an increase in the dyspnea and other severe symptoms, is a bad 
indication. A prolonged and decidedly intermittent temperature, lasting 
for some time, may suggest some complication, such as tuberculosis, em- 
pyema, or septic infection of the ear. In primary bronchopneumonia the 
temperature curve is similar to that of lobar pneumonia ; it rises suddenly, 
remains high for from five to seven days, and then drops to normal, usu- 
ally terminating by crisis. 

The Urine. — The urine, in a large percentage of the severe cases, con- 
tains a small amount of albumin with perhaps a few hyalin and an occa- 
sional granular cast. This condition of so-called acute degeneration of 



460 



BKONCHOPNEUMONIA 



the kidney, which may occur in all febrile and toxic conditions, is of com- 
paratively little importance. The urine clears up when the bronchopneu- 
monia disappears, and very rarely, indeed, does acute Bright's disease 
develop. 

Sputum. — The sputum, from the standpoint of diagnosis, is of com- 
paratively little importance, because it is so difficult to obtain. In infants 
it is rarely, if ever, justifiable to attempt to obtain the sputum by insert- 
ing a gauze-wrapped finger into the pharynx. In older children, in whom 
tuberculous bronchopneumonia is suspected, this process may be successfully 



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RESPIRATION 5 


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oa>« o<v«>Oo£Scoo«-c»ccoo*o*oj<»c#5« a>e»ocorN,*a.o 
a> co «r <jf-^«)«>22 ,ntt, ff»'- co CO r- r* c-.-ccih.Oo-. o>»-.«dcoi--cdCO'X> 



Fig. 74. — Severe Bronchopneumonia. 



used, and the finding of tubercle bacilli in the sputum changes both the 
diagnosis and prognosis. 

Physical Signs. — In the beginning, when small areas of consolidation 
are scattered widely throughout the lungs, percussion is of little value, as 
the note thus elicited is either normal or slightly emphysematous. Later 
in the disease, when these small islands of consolidation have coalesced, 
dullness may be elicited on light percussion ; this is the more readily found 
posteriorly in the lower portion of the lung. At times large areas of con- 
solidation may occur, giving rise to physical signs very similar to those of 
lobar pneumonia. Auscultation is of great value in confirming the diag- 
nosis of bronchopneumonia, since in well-developed cases one can usually 
discover fine moist rales over small areas widely distributed, especially in 
the region of the spine and base of the lungs, and they may also be found 
anteriorly and laterally. Coarser moist rales may also be heard rather 



TYPES OF BRONCHOPNEUMONIA 461 

widely distributed. The fine crepitant and subcrepitant rales found in 
bronchopneumonia differ from those of lobar pneumonia, in that they are 
more widely distributed, occurring in small areas over both lungs; they 
are also more evanescent, disappearing at one point and reappearing at 
another. As larger portions of the lung become consolidated, they may be 
found over larger areas and may be associated with bronchophony and 
bronchial breathing. The crying and coughing of the child often develop 
or make more pronounced the physical signs. The pulmonary inflamma- 
tion is more marked in the lower portions of the lungs, and comes to the 
surface more readily posteriorly than it does anteriorly, because of the 
dorsal position of the child during its illness; as it lies so continuously 
upon its back the lower and posterior portions of the lungs are not properly 
drained. 

Types of Bronchopneumonia. — Many variations from the ordinary type 
are seen. The most important of these is primary or pneumococcic broncho- 
pneumonia. The onset and temperature curve of this condition is very 
similar to that of lobar pneumonia ; it runs a definite course, terminates by 
crisis in from five to nine days, and is followed by a rapid convalescence. 
The general clinical picture of this condition has already been described 
in the chapter on Lobar Pneumonia. 

An abortive type of pneumonia is recognized by all clinicians. Cases 
of bronchopneumonia as well as of lobar pneumonia are seen, which begin 
with the typical onset and show the characteristic symptoms and physical 
signs of these diseases, in which suddenly, on the third or fourth day, the 
temperature falls to normal, the general symptoms as well as the physical 
signs disappear, and a rapid convalescence follows. These cases are de- 
scribed by some authors under the term "Acute Pulmonary Congestion," 
but there is ample clinical and pathological proof that many of these cases 
are pneumonia. 

Prolonged bronchopneumonia with migrating areas of consolidation is 
commonly produced by the influenza bacillus. 

Bronchopneumonia of the New-born. — During the first weeks of 
life bronchopneumonia is a very insidious disease, and usually occurs as 
the sequel of epidemic grippe or influenza. The earliest symptoms are 
cold in the head, nasal catarrh, slight cough, and pharyngeal irritation, 
followed perhaps by laryngitis, bronchitis, and finally bronchopneumonia. 
The progress of the disease, however, in the infant is so masked that it is 
likely to be overlooked. There is but slight elevation of temperature as- 
sociated with an increasing cough and slight dyspnea, and as the infant 
of this age has so little resistance, a well-marked and incurable broncho- 
pneumonia not uncommonly develops before serious disease of the lung is 
suspected. At this age the disease is nearly always associated with gastro- 
intestinal disturbances, which hasten its unfavorable termination. Al- 
though this condition is comparatively rare and is most commonly seen 
in weaklings, yet the fact that it may develop so insidiously should make 
the physician most careful to give prompt attention to all catarrhal diseases 



462 BRONCHOPNEUMONIA 

of the upper air passages in young infants. Little can be done to save 
them after the bronchopneumonia has developed, but much can be done to 
safeguard them against this disease if the early catarrhal conditions are 
properly looked after. 

Deglutition Pneumonia. — Following intubation, and paralysis of the 
soft palate, food particles infected in the diphtheritic throat may be as- 
pirated into the lung and cause pneumonia. It is not the foreign body 
but the infection it carries with it that causes the localized inflammation 
of the lung. In whooping-cough the deep inspiration which follows the 
paroxysm of cough may suck particles of food far into the branches of the 
bronchial tree. If these foreign particles are infected and become lodged, 
they may excite a localized bronchopneumonia, terminating in abscess. 
Noninfected food particles or other clean foreign bodies may cause bron- 
chial irritation, but not bronchopneumonia. 

Bronchopneumonia Following Gastroenteritis. — One of the dan- 
gers of chronic and subacute enteritis is a complicating bronchopneumonia. 
In many of these cases it is a terminal infection, occurring but a short 
time before the fatal issue. Terminal bronchopneumonia may also occur 
in other wasting diseases. 

Tuberculous Bronchopneumonia. — This is one of the common forms. 
In the beginning it presents the picture of an ordinary bronchopneumonia, 
but fails to clear up in three or four weeks, although the temperature and 
acute symptoms may have somewhat subsided. It occurs most frequently 
in infancy, but may occur in older children. The cough is tenacious, the 
dyspnea is marked, although not excessive, the fever is remittent, some- 
times intermittent, falling in the morning and rising to 104° or 105 °F. in 
the afternoon. The sharp exacerbation in temperature which occurs at 
least once in twenty-four hours does not always come at the same time of 
the day. There is progressive emaciation and loss of strength, and the 
disease may continue for five or six weeks. As it progresses, large areas 
of consolidation appear; the whole of both lobes posteriorly may be con- 
solidated, or the consolidation may be in other parts of the lung. Over 
these consolidated areas there is marked dullness, tubular breathing and 
bronchophony, and large and fine rales may be heard. The physical signs 
are, in fact, almost identical with those of lobar pneumonia. The diag- 
nosis may sometimes be made by examining the sputum. As a rule, there 
is a family history of tuberculosis, with perhaps a previous personal his- 
tory of glandular tuberculosis. The areas of consolidation are persistent 
and do not shift, as in other forms of prolonged bronchopneumonia. 

Complications. — Pleurisy is as important, although not so common, a 
complication of bronchopneumonia as it is of lobar pneumonia. When it 
does supervene, however, it is usually purulent in character. An empyema 
complicating a bronchopneumonia may prolong the fever and cause the 
temperature curve to assume a septic type, falling to normal or below 
normal in the morning and rising rapidly to 104° or 105 °F. in the after- 
noon; it does not always reach its highest or its lowest point at the same 



DIAGNOSIS 463 

hours every day, and there may be more than one such exacerbation dur- 
ing the twenty-four hours. This irregular, sharply remittent or intermit- 
tent fever, following a bronchopneumonia, usually indicates either em- 
pyema, otitis media, or a complicating tuberculosis. The differential diag- 
nosis between these conditions must be made by the associated symptoms. 
Otitis media is a frequent complication. It may produce the septic tem- 
perature curve above described, and under these conditions, if empyema 
and tuberculosis can be excluded, the existence of an otitis media becomes 
more probable. Moreover, it is usually associated with pain, so that the 
increased restlessness, sleeplessness and irritability of the child may sug- 
gest to the physician the possibility of earache, and an examination of 
the ear drum may confirm the diagnosis. Not infrequently, however, 
this complication is overlooked until the mother or nurse announces that 
the patient has a purulent discharge from the ear. Pericarditis is a rare 
complication. When it does occur, however, it is nearly always purulent 
and leads to a fatal issue. A weak and dilated heart muscle may be an 
unfavorable complication in cases of bronchopneumonia, associated with 
severe attacks of whooping-cough. Meningitis, arthritis and osteomyelitis 
are possible complications. 

Diagnosis. — In lobar pneumonia, as previously noted, it is often a ques- 
tion of the organ involved, as the symptom group in this disease may be 
so misleading that the physician's attention is not called to the lung as 
the site of the disease. This very rarely occurs in bronchopneumonia. In 
this disease the pulmonary symptoms are so prominent that attention is 
at once directed to the lungs. The only question, therefore, which is likely 
to arise is as to the character of the pneumonia. Is it a lobar, or a 
bronchopneumonia? If the latter, what is the character of the broncho- 
pneumonia? As the differential diagnosis of the different forms of bron- 
chopneumonia have already been considered, it only remains here to note 
the points of difference between lobar and bronchopneumonia. When the 
characteristic physical signs of these diseases are well defined there is little 
difficulty. In lobar pneumonia we may have large areas of consolidation 
confined to one lobe, with marked dullness, bronchial breathing, and sub- 
crepitant rales scattered over this consolidated area, the other portions of 
the lungs being comparatively free from physical signs. In bronchopneu- 
monia the dullness may be absent, but fine crepitant and subcrepitant rales 
may be found from time to time in small areas scattered rather widely 
over both lungs, and with this we have coarser rales in the larger bronchi. 
Unfortunately, however, these clearly defined physical signs are not always 
present, or they may be so commingled in an individual case that the physi- 
cian is left in doubt as to the character of the pneumonia. For these rea- 
sons the clinical history of the two pneumonias is of quite as much im- 
portance as the physical signs in making a diagnosis. Bronchopneumonia 
differs from croupous pneumonia in that it is usually a secondary disease, 
having a more gradual onset. Its temperature curve is not at all char- 
acteristic, being irregular in character and running no definite course, and, 
31 



404 BRONCHOPNEUMONIA 

most important of all, dyspnea and possibly cyanosis may be marked and 
early symptoms. The early and more or less characteristic dyspnea, which 
has above been carefully dwelt upon, is of great value in differential diag- 
nosis. 

Prognosis. — This is one of the most serious and dangerous diseases of 
early life. Even under the most favorable conditions the death rate is 25 
per cent. In hospitals and other institutions, where children are crowded 
together, the mortality may reach from 40 to 60 per cent, Age is an 
important factor in determining the death rate. In the new-born the dis- 
ease is almost always fatal; during the first year of life it reaches 30 to 
40 per cent.; during the second year of life it falls below 25 per cent., and 
thereafter continues to diminish, until between the third and fifth year of 
life the mortality, under favorable conditions, generally does not exceed 
10 per cent. The physical condition of the child greatly influences the 
death rate. The mortality is very high in syphilitic, rachitic, tuberculous, 
and other malnourished infants, and when associated with enteritis is al- 
most always fatal. The mortality is much greater in bottle-fed than in 
breast-fed infants. The death rate is higher in the middle and northern 
States during the cold and changeable winter months, because this climate 
and this season are not so favorable to the fresh-air treatment of this dis- 
ease. The mortality is also influenced by the character of the infection 
which produces the bronchopneumonia. In tuberculous cases it is bad. In 
pneumococcic or primary bronchopneumonia the prognosis is good; nearly 
all of these cases get well, except those which occur in weak and delicate 
infants during the first year of life. The mortality is higher in the cases 
following diphtheria, scarlet fever and whooping-cough than it is in those 
produced by measles, influenza or simple bronchitis. 

Prophylaxis. — Fresh air and good hygiene are the keynotes in the 
prophylactic treatment of this disease. Bronchopneumonia, in the vast 
majority of cases, is secondary to bronchitis, and there is little doubt that 
if children suffering from the various acute infectious diseases and from 
ordinary simple bronchitis could be isolated from other children, and could 
have fresh, pure air, uncontaminated by bacteria, bronchopneumonia would 
be a comparatively rare disease. Many of the cases of bronchitis occurring 
in institutions, and in tenement houses, are forced to breathe impure 
air, which carries secondary infections of various kinds to their bronchial 
mucous membranes, and bronchopneumonia results. The necessity, there- 
fore, of looking upon every case of bronchitis in infancy with reference to 
the possible development of bronchopneumonia is of the greatest impor- 
tance. Every case should be isolated, protected from all possible conta- 
gion, and, above all, should have plenty of fresh air. The younger the 
child the more important are these precautions. In infants, during the 
first few weeks of life, every simple coryza and pharyngeal irritation should 
receive prompt and careful attention, since at this age the prophylactic 
treatment of bronchopneumonia is the only treatment that is of any avail. 

Treatment. — The first and most important thing in the treatment of 



TREATMENT 465 

bronchopneumonia is to place the patient under proper hygienic surround- 
ings. A large, well-ventilated and isolated room is to be selected, in which 
the patient is to remain under the care of a competent nurse. All unnec- 
essary callers are to be excluded, in order that quiet may reign, and that 
the air may be as little contaminated as possible. 

Hygienic Treatment. — Fresh air is the most important curative agent 
in bronchopneumonia, even more important here than in lobar pneumo- 
nia. At all seasons of the year the windows of the room must be open, 
to give an abundant inflow of fresh, cool air. The importance of the 
fresh-air treatment of this disease cannot be exaggerated, and the laity 
must be given to understand that without it all other methods of treatment 
are comparatively useless. For many years Northrup has taught and has 
insisted that the fresh-air treatment would greatly reduce the mortality 
of this disease, and he has done much, as have thousands of other physi- 
cians, to bring the laity to understand that there is little or no danger of 
"catching cold" by the fresh-air or outdoor treatment of bronchopneumonia, 
provided it is properly carried out. What the laity calls "catching cold" 
results from exposing these patients indoors to an air that is contaminated 
with pathogenic microorganisms. Fresh, pure, cold air must, therefore, be 
had wherever the patient is located. The outdoor air of any locality is 
infinitely better than the indoor air ; so that if these cases must be treated 
in the downtown, smoky atmosphere of our closely crowded tenement 
houses, the windows should be opened and this air let in in abundance, to 
replace the contaminated air of the sick room. During winter the body 
of the child must be kept warm with proper clothing, and possibly arti- 
ficial heat. At this season the infant should always be carefully hooded 
with some warm material, and the temperature of the room in the neigh- 
borhood of the child's bed should not be allowed to fall below 60° or 
65 °F. This can be accomplished by artificial heat, even though the end 
and side windows of the room be open. The bed of the infant is not to 
be placed between the windows. 

Dietetic Treatment. — From what has been said of the seriousness 
of gastrointestinal complications, one realizes the importance of the dietetic 
treatment. If the child be a nursing infant, breast feeding must be per- 
severed in; and as the child becomes too ill to take the breast, as it almost 
always does within a few days, every effort must be made with breast 
pumps and other devices to keep the mother's milk from drying up, and 
to secure in this artificial way a certain amount of breast milk, which 
can be fed to the infant with a spoon. In artificially fed babies the food 
selected must depend upon the age and digestive capacity of the individual 
infant, the physician remembering that whatever may have been the 
digestive capacity of the baby during health, it is perhaps diminished one- 
half by an attack of bronchopneumonia. In young infants, therefore, the 
milk formula given in health should be reduced not only in strength, but 
in quantity. Predigested foods, skimmed milk, meat juice, and albumin 
water may be necessary in the feeding of young and delicate infants. The 



466 BKONCHOPNEUMONIA 

importance of this subject is so great that the clinician should understand 
that, especially in early infanc)^ it is just as important not to overfeed as 
it is to give foods which are within the digestive capacity of the individual 
infant. 

Whiskey or brandy should be given in all cases of bronchopneumonia. 
Of the two, good old rye whiskey is perhaps the better. It may be given 
well diluted with water, and sweetened if necessary. Most children can 
be induced to take it in this form without resistance. In a long-continued 
disease, such as bronchopneumonia, where the child is necessarily underfed, 
whiskey serves as a food; it keeps up the strength and prevents excessive 
waste of tissues. An infant one year of age may take 20 or 30 drops 
every four hours ; a child two or three years of age, a teaspoonf ul. Larger 
or stimulating doses of whiskey or brandy may be given in bad cases, 
especially when the amount of food taken is small. I have for many years 
used whiskey as a routine measure in all severe cases of bronchopneumonia, 
and have found that it rarely, if ever, produces gastrointestinal disturbance. 

Medical Treatment. — In beginning the treatment the bowels should 
be opened with castor oil, and this should be repeated every third or fourth 
day throughout the disease. This serves the purpose of carrying off the 
mucus which the child has coughed up and swallowed, and perhaps thereby 
prevents intestinal infection. 

Tincture of strophanthus or tincture of digitalis (the former is pre- 
ferable) should be given every four hours throughout the course of the 
disease. One drop of tincture of strophanthus is a suitable dose for a 
child one year of age, and two drops for a child three years of age. Caf- 
fein-sodium-benzoate, or salicylate, in one-grain doses by the mouth, or 
one-half-grain doses hypodermically, is a valuable circulatory stimulant, 
which may be given if the pulse becomes feeble and intermittent. 

Strychnin is another drug very widely recommended, and is of value 
both as a general tonic and as a respiratory stimulant. It may be given 
combined with whiskey, 1/300 of a grain every three or four hours, to 
an infant one year of age, and 1/200 of a grain to an infant two years 
of age. The chief objection to the use of strychnin is that its bitterness 
makes the whiskey unpalatable, and for this reason it often becomes neces- 
sary to force the infant to take this combination. It is a wise policy, and 
one that should be followed within limits, to cater to the tastes of infants 
both in food and medicines when they are seriously ill with any disease. 
It may, therefore, be unwise to attempt to mix with the whiskey unpalatable 
medicines which will cause the infant to struggle against their administra- 
tion. Forcing either foods or medicines into the stomach of a child very 
ill with bronchopneumonia not only exhausts the strength, but often 
causes vomiting. The use of strychnin, therefore, is perhaps better re- 
stricted to the later stages of the disease, when a respiratory stimulant is 
urgently needed and should then be given hypodermically. Oxygen is a 
good respiratory stimulant, and before the days of the fresh-air treatment 
was one of the most valuable remedies. It still, however, has a place in the 



TREATMENT 467 

treatment of this disease, even when the child is getting all the fresh air 
it can possibly have. It is especially indicated in the later stages when the 
inspiratory dyspnea is very marked and cyanosis is present. It is easily 
administered by inhalation without disturbing the child ; the funnel which 
is connected with a tank of oxygen by rubber tubing is suspended just above 
its mouth and nose. 

Sedatives must be used with great care in bronchopneumonia, and they 
are of much less value here than in lobar pneumonia. The temptation 
is very great to try to influence with sedatives the irritable and harassing 
cough of bronchopneumonia. But it should be remembered that the young- 
er the child the more dangerous is all sedative medication. Opiates are 
rarely indicated under two years of age. Now and then, perhaps, a sturdy 
infant with a severe and harassing cough may be slightly benefited by a 
few drops of paregoric or a small dose of codein. But within the last ten 
years I have not in a single case thought it advisable to give opium in 
any form to a patient under two years of age. Opium produces constipa- 
tion, destroys the appetite, disturbs the digestion and does much more harm 
than good. I believe that the injudicious use of opium as a cough seda- 
tive has in the past been responsible for no small percentage of the deaths 
produced by bronchopneumonia. Opium, therefore, should, with the ex- 
pectorants and medical antipyretics, be classed among the dangerous rather 
than the beneficent remedies in bronchopneumonia. Bromid of potash 
in four- to five-grain doses, with tincture of belladonna in one-minim doses, 
may, when combined in some palatable vehicle, serve a useful purpose as a 
cough sedative in certain cases, but even these drugs find their greatest indi- 
cation in children over two years of age. Under this age they should be 
used only when absolutely necessary and should be discontinued if they 
produce the slightest gastric or intestinal disturbance. 

Expectorants should have no place in the treatment of bronchopneu- 
monia in children under two years of age. Tartar emetic, syrup of 
ipecac, syrup of squill, carbonate and muriate of ammonia, in my opin- 
ion, do more harm than good. The widespread use of these drugs is, I 
believe, responsible for no small part of the mortality of this disease in 
early infancy. They may dislodge a certain amount of mucus in the 
throat and upper air passages, but the temporary improvement in the 
breathing, produced in this way, is more than counterbalanced by the harm 
they do in destroying the appetite, disturbing the digestion, and cutting 
off the nutrition of the child. In a long and. prostrating disease, such as 
bronchopneumonia, any medicine that interferes with nutrition or disturbs 
the appetite or digestion will do more harm than good. In older children 
the careful use of these expectorants may perhaps be of value. 

Antipyretics are of much less value and are much less frequently called 
for in bronchopneumonia than in lobar pneumonia. The fever of broncho- 
pneumonia is remittent or intermittent in type, and little or nothing is 
to be gained by drugs or other agents used for lowering the temperature. 
Phenacetin, antipyrin, and other drugs of this class, which may occasionally 



468 BRONCHOPNEUMONIA 

be used to advantage in older children suffering from lobar pneumonia, do 
much more harm than good in bronchopneumonia. Cold packs, which are 
of value in many cases of lobar pneumonia, are not so generally used in 
bronchopneumonia, and they are, in my opinion, decidedly contraindicated 
in infants suffering from marked inspiratory dyspnea or cyanosis. A 
warm bath twice a day, or a tepid sponge bath three or four times in 
twenty-four hours, is of value. These baths act as a sedative to the nervous 
system, promote elimination through the skin, and serve as a general tonic 
to nutritional processes. They are not given with the idea of lowering 
the temperature. Priessnitz applications are of value in both forms of 
pneumonia ; a light, sleeveless flannel jacket made to fit the child is dipped 
in and wrung out of water at a temperature of 70°F. ; this is snugly ap- 
plied to the entire chest and covered with a similar dry flannel jacket. The 
wet jacket may be removed and reapplied at intervals of from y 2 hour to 
3 hours, as the exigencies of the individual case demand. 

Counter-irritants and Poultices. — Nearly all writers, at the present 
time, recommend counter-irritants and condemn poultices. Notwithstand- 
ing this almost universally expressed opinion, I believe that the present- 
clay teachings are too liberal in their recommendation of counter-irritants, 
and too sweeping in their condemnation of poultices. Counter-irritation is 
of much less value in bronchopneumonia than it is in lobar pneumonia. 
If a counter-irritant is applied to the chest of an infant suffering from 
bronchopneumonia, it must, to do any good, cover the skin of the entire 
chest, or be applied with special severity to the skin covering its posterior 
surface. Counter-irritations with mustard plasters and mustard baths fre- 
quently do more harm than good; to be of any value they must redden 
the skin and produce more or less discomfort and irritation, and this in- 
creases the child's restlessness, nervousness and sleeplessness, without per- 
haps producing any favorable influence on the general and widespread in- 
flammation of the lungs, which .is seated some distance beneath the skin. 
If counter-irritation of any kind is used, I much prefer warm camphorated 
oil of double strength. When this is rubbed into the chest of the child it 
produces a mild counter-irritation, and the camphor, some of which is per- 
haps absorbed, acts as a general stimulant. On the other hand, poultices 
and the oil-silk jacket so universally condemned are of great value in the 
early stages of bronchopneumonia when the disease is spreading, or when 
it is passing over from a general bronchitis into a capillary bronchitis, or 
bronchopneumonia. I believe that a thin, light, warm flaxseed poultice 
spread over the back and chest of the child and covered with oil-silk, is a 
remedy of the very greatest value in preventing the extension of this 
disease. Poultices, when properly used in connection with the open-air 
treatment, do not make the child uncomfortable or increase its tempera- 
ture; on the other hand, they are sedative, rather than irritating, but they 
can be successfully managed only when the patient is under the care of 
nurses who understand how to make and how to apply them without un- 
necessarily exposing the infant to draughts of cold air. It has been my 



TREATMENT 469 

practice to change the poultices at intervals of two hours, and when this 
is done the patient is carried for a few minutes from the cold room into 
an adjoining room, and as soon as the poultice is adjusted, he is imme- 
diately returned to his fresh-air chamber. The poultice is of especial value 
in the very onset of bronchopneumonia, and is to be used only during the 
time the disease is progressing. The oil-silk jacket lined with a thin 
layer of cotton-wool may be used where the poultice cannot be satisfactorily 
handled, and it may be substituted for the poultice after its discontinuance. 
After many years of experience with the oil-silk jacket and the poultice, 
I am to-day a firm believer in their efficacy, and think they are the most 
important agents we have for stopping the spread of bronchopneumonia 
in its early stages. I fail to see what possible harm they can do when 
combined with the open-air treatment of this disease. I have, in connec- 
tion with the oil-silk jacket, for many years used the following prescrip- 
tion, which is to be applied as an inunction to the chest of the child twice 
in twenty-four hours : 

Guaiacoli 3 j 

Lanolini anhydrous q. s. ad § i 

One-half level teaspoonful applied as an inunction to the chest twice 
a day. 

This guaiacol-lanolin prescription, when well rubbed in, is readily ab- 
sorbed, the guaiacol appearing in the urine within two hours after its 
application. The guaiacol thus administered, while it may never reach 
the pulmonary mucous membrane, certainly acts as a lymphatic antiseptic, 
and as it passes from the skin through the lymphatics it may favorably 
influence the lymphatic involvement which always occurs in bronchopneu- 
monia. This drug, administered in this way, is of especial value in those 
cases complicated by lymphatic or pulmonary tuberculosis. 

Treatment During Convalescence. — Following the disappearance of 
the acute symptoms, there is usually a period of slow convalescence; the 
child is weak, nervous and anemic. During this time the fresh-air treat- 
ment is to be continued, and a carefully selected diet suitable to the nu- 
tritional demands of the child prescribed. One of the thick malt extracts 
combined with cod-liver oil or iron, or some form of arsenic, or syrup of 
the iodid of iron, or hydriodic acid, may be valuable tonics during this 
period. In children predisposed to tuberculosis creosote, or the benzoate 
or carbonate of guaiacol may be given with benefit. 



470 PLEUEISY 



CHAPTEE LIU 
PLEURISY 

Pleurisy is an inflammation of the pleura, usually secondary to infec- 
tion elsewhere, most commonly in the lungs. This inflammation may 
occur either without or with effusion into the pleural cavity. The former 
is called dry pleurisy. The latter occurs in two forms, the serofibrinous 
and purulent, depending upon the character of the exudate ; these are fre- 
quently commingled, the case beginning as a serous and later becoming a 
purulent pleurisy. The dry form is not so infrequent as clinical records 
would indicate; it is commonly overlooked, being masked by the accom- 
panying pneumonia, or other causative disease. The purulent form (em- 
pyema) is both relatively and actually much rnore common in the child 
than in the adult. 

Etiology. — Infection with pathogenic microorganisms is the cause of 
this disease. In infancy and childhood the pneumococcus is the common 
cause; this is especially true of the purulent form (empyema). Koplik 
found this organism in 75 per cent, of his cases; Netter, Beck, and other 
investigators report similar findings. The percentage of cases due to the 
pneumococcus is greatest in infancy, and slowly diminishes with advancing 
childhood. Infantile empyema is nearly always due to this organism, while 
in the adult only about 25 per cent, of the cases are due to this cause. 
Streptococci and staphylococci are the next most common organisms asso- 
ciated with pleurisy; these cases usually occur as septic complications of 
the acute infectious diseases; they are not as common in the infant and 
young child as in the older child and adult. Of special interest is the fact 
that tubercle bacilli are much less frequently a cause of pleurisy in the in- 
fant and young child than in the adult. Tuberculous pleurisy is a com- 
paratively common disease in adult life, while in childhood only about 4 or 
5 per cent, of the cases are due to this cause. In a fair percentage of tuber- 
culous pleurisies neither the tubercle bacillus nor other microorganisms 
can be demonstrated in the fluid. Negative findings in the purulent exu- 
date are suggestive of tuberculosis, but even when these negative cases are 
included the percentage of tuberculous pleurisies remains as low as above 
stated. Other microorganisms, such as the typhoid, colon, and influenza 
bacilli, may produce pleurisy, but these cases are relatively rare. 

Pleurisy may be a primary disease, but in the vast majority of the 
cases it is secondary. The primary cases are, usually, the first manifesta- 
tions of a rheumatic or pneumococcic infection. The secondary cases, for 
the most part, are associated with or occur as complications of lobar 
pneumonia, bronchopneumonia, or acute bronchitis. The various acute in- 
fectious diseases, especially rheumatism, influenza, scarlet fever, diphtheria, 
follicular tonsillitis, measles, whooping-cough, typhoid fever, tuberculosis, 



PATHOLOGY 471 

chronic gastroenteritis and septicopyemia, may produce pleurisy. In the 
new-born sepsis is the most important cause. 

Pleurisy is most commonly seen between the sixth month and the sixth 
year, and occurs with diminishing frequency before and after this period. 
The serofibrinous type is occasionally observed in the infant, becomes 
more common after the third year, and occurs with increasing frequency 
from this time on, so that in later childhood and adult life it is much 
more common than purulent pleurisy. 

Pleurisy occurs more frequently in boys than in girls, and is much 
more prevalent during the cold, damp months of winter and spring than 
it is in the warmer and dryer months. Exposure to damp, cold weather or 
"catching cold" is perhaps an important exciting cause, which can act, 
however, only by producing a more favorable soil for the microorganisms 
which cause this disease. 

Pathology. — On post-mortem examination old pleural adhesions, with 
more or less marked thickening of the pleura, may be found in children 
dying of other diseases; such unsuspected lesions commonly result from 
the dry or fibrinous form of pleurisy. In this form, during the acute 
stage, there is found on the congested, inflamed, and thickened pleura a 
fibrinoplastic exudate, with perhaps a slight amount of yellow serum in 
the pleural cavity. The rubbing together of these roughened surfaces 
produces the characteristic friction rub. The effusion and exudate in these 
cases are absorbed, leaving the pleural surfaces, adherent or bound together 
by fibrinous bands at certain points. These adhesions, however, produce 
little or no damage, since they do not to any extent interfere with lung 
expansion. 

Pleurisy with effusion presents a very different pathological picture. 
Whatever may be the character of the effusion, the lung is pressed up- 
ward until there is very little expansion on the affected side. The pleural 
cavity in these cases is filled with serous, seropurulent or purulent fluid, 
which, in a small percentage of cases, is tinged with blood. Not infre- 
quently this exudate is encapsulated and thereby separated from the rest 
of the pleural cavity, or in rare instances more than one encapsulated 
sac of fluid may be held between the pleural surfaces, so that the tapping 
of one of these cavities does not reach the other. In properly treated cases, 
especially those in which the fluid is serous, complete disappearance of 
the effusion may be obtained with comparatively little damage to the 
pleural cavity, and with little or no diminution of the respiratory capacity 
on the affected side. The lung in these cases refills the chest cavity, and 
the resulting pleural adhesions have little or no influence in impeding 
respiratory movements. In other cases, more especially in empyema, there 
is great danger that extensive pleural adhesions will not only obliterate 
the pleural cavity, but that the lung on the affected side may remain in 
a state of partial shrinkage due to the inflammatory adhesions. In such 
instances the respiratory capacity of the lung may be greatly diminished 
and the resultant deformity of the chest and spine be very great. Un- 



472 PLEUEISY 

treated cases of empyema may ulcerate either through the parietal or 
visceral pleura, on the one hand producing a subcutaneous abscess, or 
on the other discharging the pus into the bronchial tubes. The quantity 
of fluid may reach from 1,000 to 4,000 c. c. 

Symptomatology. — General Symptoms. — Pleurisy is commonly mani- 
fested by fever, cough, pain in the chest, disturbances of respiration and 
rapid pulse. Any or all of these symptoms may be absent in individual 
cases, but on the whole, in well-marked pleurisy, especially where there is 
an effusion in the pleural cavity, this symptom group in whole or part is 
present, and with it headache, vomiting and constipation are not infre- 
quently associated. 

In the most common group of cases, those following lobar or broncho- 
pneumonia, the pneumonia usually runs its course with its characteristic 
symptoms, but following the fall in temperature between the seventh and 
the tenth day the patient fails to convalesce, there are a secondary rise of 
temperature, an aggravation of the cough, sharp pain in the chest, in- 
creasing dyspnea, rapid pulse, and a careful physical examination reveals 
a beginning pleurisy. In other instances the pleurisy supervenes during 
the pneumonia, and may become at once the dominant symptom group; 
in these cases the prolongation of the fever with the cough, dyspnea, pain 
in the chest and rapid pulse are important symptoms indicating this com- 
plication. The fever may reach 104° or 105 °F., and the pulse may run 
above 160. In another group of cases, much less common, the pleurisy 
appears as a primary disease; in this variety the patient is taken suddenly 
ill with headache, vomiting, and chilliness, and the fever rises to 102° 
or 103 °F., and the hacking cough, pain in the chest and shallow, rapid 
breathing quickly develop. In still another group of cases the disease is 
not announced by acute symptoms; the child for a week or ten days is 
languid, has perhaps a slight cough, little or no appetite, gradually loses 
strength, becomes more or less anemic, has a slight intermittent fever, 
with more or less marked night sweats, and during this time, while it is 
clearly evident that the child is ill, there may be little to call attention to 
the fact that he has a well-marked pleurisy with an effusion in the pleural 
cavity. The character and even the location of the disease in such cases 
are finally revealed by physical examination of the chest. 

Individual Symptoms. — The fever in the serofibrinous form, while 
it may be high in the beginning, quickly subsides and runs an irregular 
course, reaching 101° or 102° F. Under proper treatment it usually 
becomes normal within a week or ten days. In empyema the fever is 
irregularly intermittent or remittent, rising to 104° or 105°F., and fre- 
quently falls to normal or below normal; when due to pneumococcic infec- 
tion the variations in temperature are not so marked, but when due to 
sepsis following the acute exanthemata it is characterized by rapid rises 
and falls, and is commonly associated with sweating. Following drainage 
of the pleural cavity, it should run a mildly intermittent course until 
convalescence is established. 



SYMPTOMATOLOGY 



473 



Pain in the side of the chest aggravated by coughing and by deep 
inspirations, is one of the most significant and valuable symptoms. It calls 
attention to the location and na- 
ture of the disease. The "stitch" 
in the side is an early symptom 
which usually disappears when the 
effusion has increased sufficiently 
to have separated the pleural sur- 
faces. It should also be remem- 
bered that in young children the 
pain caused by coughing and in- 
spiration is not infrequently re- 
ferred to the abdomen. 

The cough is irritating, dry, 
hacking and painful, and the pa- 
tient makes an effort to suppress 
it. The anxious, worried, and 
pained expression which spreads 
over the face of the child when it 
feels it can no longer suppress the 
cough is very suggestive of pleu- 
risy. With the appearance of the 
effusion, the cough may become 
less painful and less frequent. 

Respiration is more or less 
painful, and the child breathes 
superficially so as to limit the 
chest expansion. The respiratory 
movements are rapid and are ac- 
companied by grunting; dyspnea 
is usually a gradually increasing 
symptom, which after a time be- 
comes very marked. In its efforts 
to suppress respiratory movements 
on the diseased side the child lies 
on the affected side, and makes the 
unaffected lung do as much of the 
work as possible; this attitude is 
most suggestive and characteristic. 
As the pleural cavity fills, the 
respiratory movements are less 
painful, but the dyspnea and rapid 
breathing are more marked. 

In left-sided pleurisy with ef- 
fusion, the heart is displaced and impeded in its action by the accumulating 
fluid. In these cases the pulse, which is at all times rapid, may reach 





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PLEURISY 



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especially about the lips, and the child gradually grows more anemic and 
emaciated. 



SYMPTOMATOLOGY 475 

In pleurisy with effusion the following points are revealed by physical 
examination : Inspection shows diminished respiratory movements on the 
affected side, and this side of the chest appears larger and the intercostal 
spaces are less evident. Palpation may show that the vocal fremitus is 
diminished or lost over that portion of the chest which is filled with fluid ; 
in extensive effusions it cannot be felt over the whole of the lower portion 
of the chest cavity. Palpation also reveals the diminished respiratory 
movement of the affected side and the increased movements on the well 
side. In left-sided pleurisy it reveals the displaced apex beat, and in right- 
sided pleurisy the lower border of the liver may be felt pushed somewhat 
downward into the abdominal cavity. Percussion gives the most valuable 
information. With the child sitting in an upright position one can, as a 
rule, outline the fluid by the dullness, which in most instances amounts to 
flatness, over that portion of the chest cavity filled with fluid. Directly 
above the line of dullness the resonant note of the lung, which may be 
almost t}mipanitic, is elicited. In many instances the upper line of dull- 
ness shifts with the position of the child, being affected by gravitation of 
the fluid. From the standpoint of diagnosis the peculiar resistance, which 
is felt by the percussing finger, is second only in importance to the dull- 
ness or flatness obtained by percussion. These two signs rank all others 
in value in the diagnosis of pleurisy, and they alone justify the introduc- 
tion of an exploring needle to ascertain not only the presence, but the 
character, of the pleural effusion. It should be remembered that, while 
the flatness elicited by percussion is commonly found in the lower portion 
of the chest, especially posteriorly. ' it may also be found in other parts 
of the chest, being there produced by encapsulated fluid, and that the 
dullness elicited over these encapsulated areas may not amount to absolute 
flatness. In some instances, especially when the encapsulated fluid exists 
along the back of the lung, one may on deep percussion obtain a slightly 
resonant note from the lung situated beyond the fluid. Attention should 
also be directed to the fact that where the pleural cavity is filled with 
fluid, and the lung is pressed upward and forward, a very resonant tym- 
panitic note may be obtained at the apex anteriorly, while all the re- 
maining portion of the chest is flat on percussion and gives a peculiar 
board-like resistance to the percussing finger. In these cases of extensive 
effusion the dullness extends beyond the opposite border of the sternum. 
Auscultation is of much less value than percussion. Early in the disease, 
however, one may be able to hear the characteristic friction rub which 
coincides with inspiration, or expiration, or with both. The to-and-fro 
friction rub, when it can be heard, is a sign of great value. It disappears 
early with the increase of effusion and is heard again more distinctly when 
the fluid almost or quite disappears. Over the fluid the respiratory sounds 
are absent, indistinct, or distant, but on the whole the auscultatory find- 
ings in pleurisy with effusion are very unsatisfactory and at times mislead- 
ing. This applies especially to infants and young children. Bronchial' 
breathing, bronchophony, and even respiratory sounds may be heard over 
areas containing fluid. 



476 PLEURISY 

Displacement of Other Organs. — In left-sided pleurisy with effusion 
the displacement of the apex beat of the heart toward the median line is 
one of the most valuable findings; it may be pushed over as far as the 
sternum. In right-sided pleurisy the displacement of the liver downward, 
when it can be clearly demonstrated, is a valuable sign. 

Fluoroscopic examinations or X-ray pictures may locate the fluid, show 
displacement of the heart and other organs and thereby give valuable di- 
agnostic information. 




Fig. 77. — Pleural Effusion in Left Side of the Chest. 

Exploratory Puncture. — The ultimate diagnosis and also the prognosis 
will largely depend on the results of an exploratory puncture. This should 
be made at a point over the area of greatest dullness and where there is an 
almost or complete absence of fremitus. In cases where the flatness is 
extensive the point chosen should be over the lower portion of this area. 
In the average case, where the whole lower portion of the pleural cavity is 
filled with fluid, the point of selection should be the posterior axillary line, 
at the sixth interspace on the left side and the fifth interspace on the right. 



SYMPTOMATOLOGY 477 

In exceptional cases encapsulated fluid will be found over other areas, and 
the lower portion of the pleural cavity will be free from fluid, so that the 
physical examination must in every case determine the point for intro- 
ducing the needle. The child is firmly held in a sitting position, the skin 
is thoroughly cleansed, and a clean needle, attached to a syringe, is in- 
troduced from 1 to 2 cm. until it reaches the pleural cavity. The piston 
is then gently drawn and the fluid, if it be reached by the needle, will 
flow into the syringe. If fluid is not obtained it should not be sought for 
by moving the point of the needle in the pleural cavity, but it should be 
immediately withdrawn; after a second careful physical examination, to 
again determine the point of greatest flatness, the skin and needle should 
again be cleaned and the needle introduced in this place in the hope of 
striking fluid. In making this exploratory puncture a needle of fair 
size (one millimeter) should be used, as a smaller one is likely to be- 
come clogged by pus or fibrin. It should pass well under the border of 
the rib to avoid injuring the intercostal artery which runs along the 
inner and lower border of the rib. The wound left by the introduction 
of the needle should be immediately covered with adhesive plaster. There 
is almost no danger from an exploratory puncture when it is made through 
a clean skin with a sterile needle unless it be pushed through the pleural 
cavity into an infected lung, and this danger is rather remote. It is also 
important to avoid the cardiac region as much as possible so as not to 
wound the pericardium. The character of the pleurisy is determined by 
the fluid obtained by this exploratory puncture; it may be serous, sero- 
fibrinous, seropurulent, or purulent in character and may contain blood. 
A careful bacteriological examination of the fluid thus obtained may de- 
termine the character of the infection. If the bacteriological examina- 
tion shows the pneumococcus to be the dominant or sole microorganism 
present, the prognosis is better and the disease will run a milder course 
than in those' cases in which streptococci and staphylococci are found in 
abundance. Tubercle bacilli are rarely found in the fluid, not only be- 
cause tuberculous pleurisy is comparatively rare in childhood, but also 
because even in cases due to tuberculosis the tubercle bacilli are not readily 
found. Inoculation experiments with guinea-pigs may be resorted to in 
chronic cases in which tuberculosis is suspected. If the fluid be of light 
yellow color and serous in character the probabilities are that the disease 
will remain a serous pleurisy; this inference is especially true in children 
over five years of age, since, at this time of life, this form of pleurisy 
is much more common. If, however, the serous fluid is found on mi- 
croscopical examination to contain pneumococci, streptococci, or staphylo- 
cocci, and if, at the same time, it contains a considerable number of 
lymphocytes and pus cells, the probabilities are that this serous pleurisy will 
in a short time be converted into an empyema; this inference is especially 
true in young children under five years of age, since at this period purulent 
pleurisy is the most common form. The effusion, both in serous and 
purulent pleurisy, may be tinged with blood, but this is of little diagnostic 



478 PLEUEISY 

or prognostic importance. In the adult, blood is an unfavorable sign, since 
it commonly means tuberculous pleurisy, but this is not true in the child. 
At this age tuberculous pleurisy may occur without the fluid being tinged 
with blood, and again the effusion may be bloody in other forms of pleurisy. 
The presence of blood therefore in the young child is of little importance 
unless it occurs in low forms of pleurisy associated with hemorrhagic 
diseases, such as scurvy. 

Treatment. — The fresh-air treatment is quite as important in pleurisy 
as it is in pneumonia; apart from this, the disease should be treated 
symptomatically. In serous pleurisy, or in those cases in which the char- 
acter of the fluid has not been determined, the treatment for the time 
being is largely expectant. The patient is put to bed, and, if he be under 
two years of age, his diet should be liquid in character and carefully 
selected to suit his diminished digestive capacity. In older children suf- 
fering from serous pleurisy the diet should be as dry as possible but 
should fully meet nutritional demands. It is wise to give as little liquid 
as possible; milk, water, and soups should be sparingly used; meat, eggs, 
cereals, and bread, with a minimum amount of milk, furnish a nu- 
tritious diet, and one that is believed to promote the absorption of the 
serum in the pleural cavity. Saline laxatives are advisable and diuretics, 
such as acetate of potash and diuretin, may be given in doses suited to 
the age of the child; these remedies, however, apply to the child and 
not to the infant. In the infant the disease is commonly purulent, and, 
even when it is not, the remedies above mentioned can do no good. A 
cardiac tonic, such as tincture of strophanthus or tincture of digitalis, 
should be given in every case. In empyema it serves as a supporting 
measure to the heart, and in serous pleurisy, by improving the circulation 
and acting as a diuretic, it promotes the absorption of the fluid. Whiskey 
should be given as long as the septic temperature continues. Sodium 
salicylate (from oil of wintergreen), or aspirin, in doses suited to the 
age of the child, are valuable in serous pleurisy but not in empyema. The 
salicylates are especially indicated in children of gouty or rheumatic pa- 
rentage. 

Paregoric, codein, or some other preparation of opium may be neces- 
sary to relieve the pain in the side, although it is advisable to avoid 
their use as long as possible; they are perhaps never indicated in the 
treatment of this disease in infants under eighteen months of age. In 
older children, however, when judiciously used, they may be of value in 
relieving the pain in the side or the irritating and paroxysmal cough which 
prevents sleep and increases nervous irritation. The sharp pain, which 
is aggravated by the cough and by respiratory movements, may sometimes 
be greatly modified by strapping the chest wall with adhesive plaster, or, 
as Jacobi recommends, by fastening a tight towel bandage around the 
entire chest. Counter-irritation with mustard paste or mustard plasters 
is also very generally recommended for the relief of pain. With the 
onset of the disease cold applications in the form of an ice-bag wrapped 



TKEATMENT 479 

in a towel may be applied to the affected side; later, hot fomentations 
or hot poultices give more relief. 

Certain medicines, given by inunction, such as guaiacol one drachm, 
to one ounce of anhydrous lanolin, may be used to advantage. This 
ointment is to be thoroughly rubbed in, and then a warm poultice ap- 
plied; it is of special value in tuberculous cases. Iodin and salicylic acid 
may also be given by inunction, and are to be used in the strength of one 
drachm to the ounce of anhydrous lanolin. These ointments are readily 
absorbed and pass directly into the lymph and blood channels; this is 
the only manner in which these drugs should be given to children under 
three years of age, since, when given in this way, they are more effective 
and do not disturb the gastrointestinal organs. 

Aspiration of the pleural cavity for the removal of the fluid in serous 
pleurisy is not only a curative but at times it may be even a life-saving 
measure. It is perhaps not advisable to resort to aspiration in every case 
of serous pleurisy. In a minority of these cases the fluid will be spon- 
taneously absorbed and a satisfactory convalescence established within a 
period of three weeks. But, on the other hand, it should be remembered 
that aspiration can do no harm, promotes convalescence, and diminishes 
the number of permanent adhesions. Aspiration is demanded when the 
fluid has accumulated in sufficient quantity to displace the heart or em- 
barrass its action; when the pleural cavity is well filled and respiration is 
embarrassed, and in those cases in which the fluid does not commence 
to diminish in quantity during the second week of the disease. The in- 
crease or diminution in the quantity of fluid may be determined by the 
physical signs previously mentioned and by careful measurements of the 
affected side: If the tape measure shows the chest to be increasing in 
size the fluid is on the increase; if these measurements are found to be 
decreasing the fluid is gradually disappearing. In aspirating the pleural 
cavity, the Potain, or some other equally good aspirator, is to be used, and 
the aspirating needle must be large enough to allow a free flow of pus 
through it. In introducing the needle the same antiseptic precautions 
are to be observed as have been described above for the exploratory puncture. 
A sterile needle is to be introduced through the thoroughly cleansed 
skin, at a point where the exploratory puncture has located the serous 
exudate. It is well to introduce the needle just above the lower line of 
absolute flatness, so as to tap the lower portion of the fluid-filled sac. A 
sufficient quantity of serum is slowly withdrawn to relieve the pressure 
on the heart and lung. It is not necessary, neither is it wise, to with- 
draw all of the fluid; if the greater part is removed the remainder will 
probably be absorbed. In some instances it may be necessary to aspirate 
a second time. If, during the removal of the fluid, the patient complains 
of being faint, if the heart action becomes very weak, if a violent attack 
of coughing occurs, or if other uncomfortable symptoms supervene, the 
needle is to be immediately withdrawn. 

Surgical Treatment of Empyema. — When pus is present in the 
32 



480 PLEUKISY 

pleural cavity it must be evacuated at once by an incision between the ribs 
or preferably by a more radical surgical operation which comprehends the 
resection of a small portion of one or more ribs. To attempt to treat 
these cases by aspiration is, in most instances, a dangerous waste of time, 
yet Murphy advocates that the pus should be withdrawn from the abscess 
cavity by the introduction of a needle, and, following this operation, 60 
c. c. of a 2-per-cent. solution of formalin in glycerin be injected into the 
cavity. He emphasizes the point that this solution should be at least 
twenty-four hours old. This process is to be repeated every two to four 
weeks until the fluid drawn off becomes serosanguinolent and sterile; it 
will then be absorbed. In very young children an intercostal incision 
into the abscess cavity, of sufficient size to permit the insertion of a drainage 
tube, is commonly successful. It should be made under proper antiseptic 
precautions, as low down over the pus pocket as possible so as to facilitate 
proper drainage. This simple operation may, as a rule, be made under a 
local anesthetic, such as a weak solution of cocain, injected into the 
superficial layers of the skin at the site of the operation. In introducing 
the knife, it is important to avoid the intercostal artery which lies along 
the lower border of the rib. Following the incision, one or two short 
drainage tubes, held by safety-pins, should be inserted into the cavity, 
and drainage may be facilitated by one of the suction methods later referred 
to, or the site of the operation may be well padded with gauze to absorb 
the pus and a light bandage applied to hold it in position. If the gauze 
method of dressing is used it should be removed one or more times daily. 
If the drainage is good a satisfactory recovery commonly results. This 
is especially true of the pneumococcic form of empyema, so common in 
young children. In children over three years of age, as well as in 
younger children, in whom the above simple operation is not successful, 
the abscess cavity should be drained by the excision of a small section of 
one or more ribs. In this operation the periosteum should be stripped 
back and the incision made through its posterior layer. In aggravated 
cases it may be necessary to make a rib exsection at two points of the 
chest, anteriorly and posteriorly, in order to obtain more perfect drainage. 
The opening or openings thus made should be large enough to receive 
two rubber drainage tubes, and through these the cavity may be irrigated 
with ordinary antiseptic solutions (not peroxid of hydrogen). The op- 
eration of preference, however, in practically all cases is to make one rib 
exsection rather low down over the pus pocket, insert two drainage tubes, 
and employ light continuous suction by one of the recently devised methods 
for this purpose. In this way the pus cavity is not only properly drained 
but the lung is kept in a state of expansion and sinuses are obliterated. 
Of the various types of apparatus devised for draining the abscess cavity 
and preventing lung collapse the following are the simplest and most 
generally applicable : Bryant's method, in which a deflated Politzer bag 
is attached to the drainage tube and strapped to the chest. Brewer's 
method, especially applicable in young children, consisting of a glass 



TREATMENT 



481 



funnel, securely placed against the chest with its wide mouth covering the 
drainage tubes, the suction being secured by means of a pump connected 
by a rubber tube to the small end of the funnel. 

Collapse of the lung during operation may be prevented by Meltzer's 
method, modified by Elsberg. This consists in pumping air into the 
lungs during the operation for empyema through a tube, considerably 
smaller than the lumen of the trachea, passed far into the trachea through 
the glottis. Under this method the air enters the lung through the tube 
and escapes around the tube, and sufficient pressure is thereby maintained 
to prevent collapse of the lungs. A number of other methods have been 
devised having the same object as the Meltzer method. The ideal operation 
for acute empyema would be to evacuate the pus by thoracotomy, under 
a method which would hold the lung close to the chest wall, and then 
apply an air-tight dressing or, as RansohofT suggests, grasping the lung 
and sewing it to the wound margin while under the differential pressure, 




Fig. 78. — James Apparatus for Expanding the Lung. 

and then applying one of the suction or ordinary drainage methods above 
described. 

Following the operation the lung should be kept as quiet as possible 
for four or five days and then should be encouraged to expand by active 
breathing exercises, or by the use of the apparatus devised by James for 
expanding the lung. This consists of two bottles connected by rubber 
tubing, each being one-half filled with fluid. The child amuses itself by 
blowing the fluid from one bottle to the other and in this way obtains an 
excellent pulmonary exercise which assists in the expansion of the con- 
tracted lung. 

Bilateral Empyema. — This is comparatively rare, but when it does 
occur the left side should be operated upon first and the opposite side 
a week or two later. When rib excision is performed on the left side the 
right side may be aspirated, and, if necessary, this aspiration may be 
repeated from time to time to prevent the accumulation of pus in quan- 
tities sufficient to seriously impede respiratory movements. 

Chronic Empyema. — Chronic empyema which has failed to respond 
to surgical methods combined with the fresh-air treatment, may be greatly 
benefited, and, in some instances, convalescence may be established by the 
use of autogenous vaccines as described in the chapter on Therapeutics of 
Infancy and Childhood. In obstinate cases it may be necessary to per- 



482 PLEUEISY 

form decortication of the lung, as recommended by Fowler, removing en 
masse the thickened visceral pleura and thus allowing the lung to expand. 
Treatment During Convalescence. — Following the disappearance of 
all symptoms in empyema all forms of exercise involving the arms and 
chest must be carefully avoided. The child should live and sleep in the 
open air and should be given a carefully selected diet within the range 
of its digestive capacity and tonics containing malt, iron, arsenic, or cod- 
liver oil may be indicated. After a period of six or more months, when 
apparently all danger of a return of empyema has disappeared, the pa- 
tient should be referred to an orthopedic surgeon for the correction of 
spinal and chest deformities. Properly directed breathing and gymnastic 
exercises may markedly diminish the resultant permanent deformity. 



PLATE V. 



V. cava superior 
Aorta ascendens 

Foramen ovale 

Valvula venae cavae 
[inferioris, Eustachii] 

Atrium dextrum 
Ventriculus dexter 

V. hepatica sinistra 

Ductus venosus 
[arantii] 



Arcus aortae 

Ductus arteriosus 
[Botalli] 



Ramus sinister 
A. pulmonalis 



Distributions 
in the liver 



V. umbilicalis 




V. portae 



A. umbilicales 



;a urinaria 



Aorta abdominalis 



A. iiiaca communis 
V. i'iaca communis 



A. iiiaca externa 



A., hypogastrica 



Scheme of the Circulation of the Blood in the Fetus 
(after Spalteholz). 



SECTION VIII 

THE HEART 

The heart muscle of the child is strong, elastic, and bears strain with 
comparatively little injury, not only because of the very great elasticity 
of the muscle cells at this age, but also because the elastic tissue surrounding 
these cells is fully developed at the age of seven (Fahr). It is in a 
state of growth and functional development, and therefore readily under- 
goes hypertrophy when called upon to do more than the normal amount 
of physiological work over a long period of time. 

The strength, elasticity, and healthful condition of the arteries during 
childhood greatly increase their efficiency in promoting and equalizing the 
circulation, and also minimize the ill effects on the circulation which 
result from inflammatory diseases of the heart and strain of the heart 
muscle during this period of life. 

In early infancy the size of the heart and the capacity of the arteries 
are relatively larger than at any other period and the capillary circulation 
is much more active. The relatively large size of the great blood vessels, 
and of the openings through which they enter and leave the heart, is of 
special physiological and pathological importance, as they give an enor- 
mous advantage to the infantile heart in promoting circulation. The in- 
fantile heart acts rapidly (110 to 120 per minute), and drives a com- 
paratively large blood stream, with little resistance, through large openings 
into large arteries which, by reason of their great elasticity, promote the 
rapid circulation of the blood so characteristic of infancy. These condi- 
tions account for the low blood pressure (80 to 90 m. m.). As the child 
grows older the heart increases in size and strength, but there is little or 
no change for five or six years in the size of the ostia, and thereafter the 
increase in the size of the heart continues to be very much greater than 
the increase in size of the ostia, so that the difference between the capacity 
of the heart and the capacity of the arteries gradually increases throughout 
childhood, and with this change there is an increase in blood pressure 
reaching 110 mm. at ten years of age. The total body weight of the 
adult is nineteen times that of the newly-born infant, but the heart is only 
fifteen times as heavy as at birth, so that the relation of heart weight 
to body weight is never again as favorable as in earliest infancy. (Hoch- 
singer. ) 

483 



484 CONGENITAL HEART DISEASE 

The younger the child the more rapid and unstable is the pulse. Dur- 
ing the first year the normal average varies from 100 to 140, and thereafter 
diminishes four or five beats a year, until at ten the average pulse is 
about 80. The arrhythmia so frequently observed in infancy is largely 
due to lack of inhibition, which results in an instability of the nervous 
mechanism of the heart; it is therefore of little pathological importance. 
Apart from the normal slight irregularity of rhythm of the infantile 
heart, which is most common during sleep, it is very easily influenced 
in its rate and rhythm by pathological conditions of all kinds. The rapid, 
irregular pulse, which is produced so readily from slight causes in infancy 
and early childhood, is not of such pathological significance as it is in 
later childhood and adult life. This is especially true of the rapid heart; 
the normally rapid pulse of the child may become almost uncountable 
from slight and evanescent causes. 

During the first five years of life the heart increases m size, strength, 
and weight, but not in circumference (Beneke). From this time to 
puberty, while its openings from and into the great vessels increase very 
slowly in size, there is much greater increase in the size of the heart, and 
yet it does not keep pace in development with the chest cavity. The long 
time that the ostia remain almost stationary favors the muscular power 
of the heart. The apex beat in infancy is commonly in the fourth inter- 
costal space, in early childhood in the fifth interspace, and in later child- 
hood slightly lower. In infancy it may be just outside and in early child- 
hood just inside the mammary line; in the older child it is found well 
within this line. This change in location of the apex is due not alone to 
the growth of the chest cavity, but is also due to the swinging of the 
heart downward and inward from the slightly oblique position it occupies 
in infancy to its perpendicular position in childhood. The area of cardiac 
dullness, while it actually slowly increases with the growth of the heart, 
gradually continues throughout childhood to occupy a smaller proportion 
of the chest cavity, and the external border of this dullness is thereby 
slowly moved from just without to within the mammary line. Its outer 
border in infancy is slightly outside the mammary line, its inner border 
the midsternal line, its lower margin the fourth or fifth interspace, and 
its upper margin the second interspace. Enlargement of the heart is deter- 
mined by a displacement of the apex beat downward or outward, and by 
an increase in the width of the cardiac dullness extending either 2 or 3 
cm. beyond the midsternal or the mammary lines. 



CHAPTEE LIV 

CONGENITAL HEAET DISEASE ' 

Etiology. — The character of the fetal circulation and the changes which 
occur in it at birth are necessary to the understanding of the etiology of 



SYMPTOMATOLOGY 485 

congenital heart disease. The most important peculiarities of the fetal 
heart are the direct communication between the two auricles through 
the foramen ovale, and the large size of the Eustachian valve which serves 
to direct the blood entering the right auricle from the inferior vena cava 
directly through the foramen ovale into the right auricle. The important 
peculiarity in the arterial system of the fetus having a bearing on con- 
genital heart disease is the communication between the pulmonary artery 
and the descending aorta by means of the ductus arteriosus. 

At birth the foramen ovale is normally closed by the increased pres- 
sure in the left auricle and thereafter there should be no direct inter- 
change of blood between the auricles. The function of the ductus ar- 
teriosus should also cease at this time and thereafter there should be no 
direct communication between the pulmonary artery and the descending 
aorta. 

Malformations, due to arrested or perverted development, are the 
most common causes of congenital heart disease. They are frequently 
associated with the persistence of the above-named fetal conditions, namely 
a patulous foramen ovale and ductus arteriosus, and they are also com- 
monly associated with congenital deformities elsewhere in the body, show- 
ing that they are due to the same general causes, producing perverted de- 
velopment in various parts of the body. Consanguinity and neurotic 
disease in the parents, and early psychic influences acting on the pregnant 
mother, may be etiologically related to these cases. Heredity may also be 
a factor. Fetal endocarditis is also an important cause of congenital heart 
disease. The acute infections, rheumatism, syphilis, tuberculosis, and 
traumatic lesions are mentioned as possible factors of this condition. 

Symptomatology. — General Symptoms. — Cyanosis, which is one of 
the most characteristic symptoms, is due to a venous condition of the 
blood and not to passive congestion of the skin from weak cardiac action. 
In aggravated cases, however, the cyanosis is increased by physical ex- 
ertion and the superficial veins of the skin may gradually become more 
or less chronically congested. Cyanosis, while a common symptom, does 
not occur in all forms of congenital heart disease. It is nearly always 
present in that most frequent of all lesions, congenital stenosis of the 
pulmonary artery, and always occurs in a very pronounced form in the 
rare congenital condition where the aorta takes its origin from the right 
heart. It is commonly absent, however, in lesions of the ventricular sep- 
tum and in open ductus arteriosus. It may occur during the first days 
of life, or it may not appear until the infant is two or three years of age. 
The earlier and deeper the cyanosis the graver the prognosis. In the 
less severe cases cyanosis may come and go, and be greatly aggravated by 
excitement and exertion. 

Bulging of the precordia is an early and frequent symptom. A hori- 
zontal increase of precordial dullness, murmurs, and retinal changes may 
also be noted. 

Dyspnea, which is a marked symptom of congenital heart disease, is. 



486 



CONGENITAL HEAKT DISEASE 



as a rule, in direct proportion to the severity of the cyanosis. It is ag- 
gravated by mental excitement and physical fatigue. Clubbed fingers are 
found, especially in those cases in which there are cyanosis and dyspnea. 
The terminal phalanges are knob-shaped and have a bluish tinge. The toes 
may also show this same deformity. 

The blood picture associated with the cyanosis presents the following 
characteristics. The blood has a dark blue color, due to excess of C0 2 
and deficiency of 0. The red blood corpuscles are increased in size 
(macrocythemia). The amount of hemoglobin in each corpuscle is in- 
creased and the great increase in the percentage of hemoglobin gives to 
the blood a very high specific gravity, sometimes reaching 1,070. The most 
characteristic blood change, however, is polycythemia; the number of red 

cells may reach 7,000,000, or even 
more. This increase goes hand in 
hand with the cyanosis, a high red- 
cell count being associated with the 
worst cases of cyanosis. The above 
blood changes are not found in con- 
genital heart diseases unassociated 
with cyanosis. 

The malnutrition and defective 
development will be in direct pro- 
portion to the physiological incom- 
petency of the heart. Curvature of 
the spine and other rachitic de- 
formities are common. 

Enlargement of the heart from 
hypertrophy or dilatation is not so 
marked or characteristic in the com- 
mon forms of congenital heart dis- 
ease as in acquired heart lesions, 
but when it does occur it extends to 
the right beyond the sternum. In some of the rarer congenital conditions 
(patulous ductus arteriosus) the cardiac hypertrophy may be very great. 

Systolic murmurs are by far the most common. They may be diffused 
over the whole cardiac area, but they are commonly heard more dis- 
tinctly at the base of the heart; diastolic murmurs are very rarely con- 
genital. Hochsinger says : "Abnormally loud cardiac murmurs in infants 
and little children are an almost infallible sign of the congenital nature 
of the existing heart affection." 

Specific Lesions. — The differential diagnosis of the various lesions 
occurring in congenital heart disease is, as a rule, difficult and ofttimes 
impossible. The chief reason for this difficulty lies in the fact that 
these lesions rarely occur singly; in nearly all instances one or more 
congenital defects are associated. Of the various lesions of congenital 
heart disease two are of special interest to the clinician, namely stenosis 




Fig. 79. — Clubbing of the Fingebs in Con 
genital Heart Disease. 



SYMPTOMATOLOGY -±87 

of the pulmonary artery and congenital defects of the ventricular septum. 
These two deformities are of special interest because they make up the 
great majority of the cases and because they are frequently associated 
in the same case. In addition to these, the following deformities occur : 
open ductus arteriosus, open foramen ovale, aortic stenosis, abnormalities 
in the origin of the great vessels and valvular anomalies involving any 
of the valves of the heart. These latter anomalies, however, are com- 
paratively rare, and when they occur are usually associated with either 
pulmonic stenosis or defects in either the ventricular or auricular septum. 

Stenosis of the Pulmonary Artery. — Most of these cases are due to 
developmental defects; the remainder to fetal endocarditis. This is the 
most common form of congenital cardiac defect; 68 per cent, are due 
to this cause (Peacock and Keith). It ranks first in clinical importance, 
because of its rather clear symptom-complex and because these cases may 
live for a long time and require medical supervision. 

Early cyanosis, associated with dyspnea, clubbed fingers, and the char- 
acteristic blood picture previously noted under General Symptoms, is an 
important part of the symptom-complex of this condition. In the great 
majority of cases there is a loud, rough, long systolic murmur heard at 
the base, its maximum intensity being in the second intercostal space just 
to the left of the sternum; it is not transmitted to the arteries of the 
neck. With this murmur a distinct thrill may be felt by placing the 
hand over the cardiac area; the absence of this sign may depend upon 
complicating cardiac defects. The heart is enlarged; the cardiac dullness 
extends to the right. The second pulmonary sound is not accentuated and 
may be absent. The above signs and symptoms, when they exist, are path- 
ognomonic of pulmonary stenosis, and in the great majority of these cases 
the symptom group is sufficiently complete to make the diagnosis clear. 
In a few instances, however, either by reason of associated defects or 
from inexplicable causes, this symptom group is so modified that the di- 
agnosis cannot be definitely made. 

Prognosis. — Many of these cases live to adult life. Those that are 
complicated with severe septum defects and other anomalies die early from 
tuberculosis, acute endocarditis, and other causes. Deep cyanosis, and 
continuous polycythemia indicate an early termination of the disease. 

Defective Interventricular Septum. — This is one of the most common 
of congenital heart lesions. It may be the only malformation, but, as a 
rule, it is associated with pulmonary stenosis, which greatly complicates 
the symptom-complex. It is also usually associated with an open foramen 
ovale, which condition, however, adds little to the symptom group. In rare 
instances the entire septum may be absent, but partial defects, usually 
located at the base, make up the majority of these cases. Of the various 
cardiac anomalies this is the one most commonly associated with de- 
formities in other parts of the body. 

When this cardiac defect exists as an independent condition it is 
characterized by a long, harsh, systolic murmur heard over the whole car- 



488 CONGENITAL HEART DISEASE 

diac area, having, as a rule, its point of greatest intensity, according 
to Roger, in the upper third of the precordial region. It is not heard 
over the great vessels of the neck, but is transmitted downward. A distinct 
cardiac thrill may be felt in many of these cases and a marked systolic 
retraction over the precordium and epigastrium may be seen. Cyanosis 
and its accompanying symptoms are, as a rule, absent; when present they 
are usually slight or intermittent. It is a notable fact that the signs 
and symptoms of this condition may be altogether out of proportion to 
the extent of the lesion. In some instances extensive defects in the inter- 
ventricular septum exist without symptoms, the condition being discovered 
post mortem. In other instances small defects give rise to loud murmurs. 
The frequent association of this cardiac anomaly with pulmonary stenosis 
leads to a confusion of the two symptom groups. In such instances cyanosis 
and its accompanying symptoms are an important part of the combined 
symptom-complex. Hochsinger says that in septum defects the systolic 
murmur is associated with an accentuation of the second sound at the 
pulmonary area, and that this materially assists in differentiating these 
murmurs from those produced by pulmonary stenosis. 

Prognosis. — In uncomplicated cases the patients may live to adult life; 
the majority of them die during childhood. 

Persistent Patulous Ductus Arteriosus Botalli. — This, as a clinical en- 
tity, is a rare condition, but occurs more frequently in association with 
pulmonary stenosis and defective interventricular septum. Cyanosis is, as a 
rule, absent in these cases, and the skin may even present a pallid wax-like 
appearance. The dilated pulmonary artery running across the base of 
the heart presents a ribbon-like band of dullness in the first and second 
intercostal spaces (G-erhardt). In Rontgen ray pictures this artery pro- 
duces a shadow "like a cap" covering the general cardiac shadow (Arn- 
heim) ; this is a most important point in differential diagnosis. There 
is a loud, long, buzzing, systolic murmur most distinct at the base and 
transmitted not downward but into the carotids, especially the left. The 
second pulmonary sound is accentuated, a distinct systolic thrill may be 
felt, and, with a systolic, a diastolic murmur is often heard following 
the accentuated second pulmonic sound. Hypertrophy of the right and 
sometimes of the left ventricle may produce a great increase in the area 
of cardiac dullness, and the systolic pulsation described by Cferhardt may 
be seen in the second left interspace where the heart strikes the chest 
wall. The above clinical picture is greatly complicated when the patulous 
ductus is associated with pulmonary stenosis, as the blending of the two 
syndromes may produce a symptom-complex in which it is difficult to 
make out with clearness either condition. 

Treatment. — The treatment of congenital heart disease is purely symp- 
tomatic and quite unsatisfactory, since all that one can do is to promote 
the comfort and prolong the lives of these children. Attacks of cyanosis 
may be relieved by the administration of oxygen. During the first days 
and months of the life of the child it may be necessary to keep up the 



ETIOLOGY 489 

body temperature by artificial heat. These feeble infants are especially 
prone to gastrointestinal disturbances and must therefore be fed with 
great care; breast-milk is ofttimes the only food upon which they can 
thrive. If the child lives, care must be exercised to prevent the development 
of spinal curvature which frequently occurs. As children of this type 
always remain weak and undeveloped they must throughout their lives 
be carefully protected from contagious diseases. 

Congenital heart lesions require digitalis only when the symptoms 
of myocardial insufficiency are very marked. 



CHAPTER LV 

ACUTE ENDOCARDITIS 

Acute endocarditis is an inflammation of the endocardium, most marked 
on and near the valves. In children especially the whole heart muscle is 
more or less involved. It is essentially an infection, but the disease varies 
greatly in severity from the simple cases which run a benign course of 
two or three weeks' duration to the septic or so-called ulcerative cases, 
which, with few exceptions, terminate fatally. The severity of these cases 
depends partly upon the susceptibility of the individual, but more on the 
character of the microorganism which is producing the inflammation. In 
fetal life the right side of the heart is usually affected. After birth the 
left is chiefly involved. 

Etiology. — It is extremely rare in infancy, uncommon before the fourth 
year, and thereafter increases in frequency until the. tenth year ; between 
this age and the fifteenth year of life it is most commonly seen. It is 
observed most frequently in the late winter and spring. Heredity is an 
important predisposing factor. 

Eheumatism is the great exciting cause. Rheumatic arthritis or chorea 
is associated with endocarditis in 70 to 80 per cent, of the cases; in order 
to understand this relationship, it should be remembered that rheumatism 
is a general febrile disease of infective origin, whose chief manifestations, 
as Cheadle has taught, are non-suppurative polyarthritis, acute inflam- 
matory diseases of the heart, and chorea. One or all of these manifesta- 
tions may be present at the same time, or any one may take precedence 
in the order of their development, but most commonly the arthritis pre- 
cedes the heart disease and the chorea. Polyarthritis and chorea are there- 
fore rheumatic syndromes, commonly associated with endocarditis, and their 
presence should make the physician ever watchful for the development 
of heart symptoms, marking the insidious onset of inflammatory disease 
of this organ. On the other hand, in searching for evidence of rheumatism 
to explain an existing endocarditis, the physician should keep in mind the 
mild character of the rheumatic polyarthritis that occurs in childhood. In 
many instances there will be a history of a mild febrile attack, with per- 



490 ACUTE ENDOCARDITIS 

haps slight indefinite pains, and joint tenderness so mild as to be dis- 
covered only on pressure. 

The lymphoid ring of the pharynx is the common portal of entrance 
for bacteria (Jacobi), and Packard has called attention to the fact that 
endocarditis in children is very commonly preceded by tonsillitis. Influ- 
enza, scarlet fever, tuberculosis, pneumonia, and septic processes in gen- 
eral may be complicated or followed by an endocarditis. 

Pathology. — The pathological anatomy of endocarditis in childhood is 
very similar to that which occurs in the adult. The different forms of 
this disease have not been definitely associated with specific microorganisms ; 
streptococci and staphylococci are most commonly found; the pneumo- 
coccus, gonococcus, typhoid bacillus, and other microorganisms are more 
rarely observed. The valves are the sites of the most marked lesions, the 
mitral being by far the most commonly affected. The endocardium is thick- 
ened, its superficial epithelium is destroyed, and fibrous vegetations occur, 
which thicken and prevent the proper closing of the valves. Small par- 
ticles may be separated from these vegetations and carried by the blood 
to distant organs, producing infarcts and secondary infections. As the 
inflammation subsides these fibrous deposits may be in great part ab- 
sorbed, but resulting contractions of the cordse tendinse or deformities of 
the valves themselves commonly result in their incomplete closure with 
a resultant incompetency or leakage of the valve. In the ulcerative form 
the vegetations are broken down by ulcerative processes and septic par- 
ticles are cast into the blood stream, thus producing a general septicopy- 
emia with localized abscesses in various organs of the body. 

Symptomatology. — An insidious onset is characteristic of endocarditis 
in childhood. This disease usually develops with few or no symptoms 
directing attention to the heart itself. Fever is present, but the irregular 
temperature curve is usually mistaken for an exacerbation of the fever of 
the rheumatism or other acute infection with which the endocarditis is 
commonly associated. Broadbent says that an intermittent or irregular 
fever in childhood, which resists quinin, often indicates endocarditis. 
Epistaxis may occur. Shortness of breath, rapid and irregular action of 
the heart, with slight precordial distress, may be present in some cases; 
this is especially true where the myocardium is involved and cardiac dila- 
tation is the first evidence of endocarditis. In other instances progressive 
wasting and anemia, unaccompanied by acute symptoms, may call for a 
careful physical examination, which reveals the cardiac bruit of endocar- 
ditis. The insidious onset of this condition, therefore, calls upon the 
physician to make a careful physical examination of the heart daily in 
all cases of rheumatism and other infections which may be etiologically 
related to endocarditis. 

The most important clinical sign of this disease is a low, Mowing 
systolic bruit, heard most distinctly at the apex, and transmitted toward 
the axillary region; this murmur means mitral regurgitation. As the 
mitral valve is almost exclusively affected in this disease the heart murmur 



SEPTIC ENDOCARDITIS 491 

has its point of greatest intensity almost always at the apex. In a small 
minority of these cases there is a mitral stenosis, which produces a pre- 
systolic apical bruit, usually associated with, but rarely independent of, 
the systolic apical bruit. Both systolic and diastolic apical bruits may 
exist for a considerable length of time without producing reduplication 
of the second sound over the pulmonary valve. Aortic disease is infrequent 
in the acute endocarditis of children. In this condition systolic murmurs 
are the more common, and have their point of greatest intensity in the 
second intercostal space to the right of the sternum; they are due to the 
roughness of the aortic valves and ostium. In rare instances diastolic 
aortic murmurs may be heard in the same location. Percussion is of little 
value, since there is little increase in the size of the heart during an acute 
attack, except in cases of acute dilatation, and here the symptoms of 
cardiac distress are so marked that the nature of the lesion can scarcely be 
overlooked. 

Septic Endocarditis. — Septic endocarditis is a term now in general use 
to describe those cases of endocarditis which are complicated by a general 
septicopyemia. They do not represent a separate or distinct disease, but 
are produced by the same microorganisms sometimes found in simple 
endocarditis. In simple endocarditis these microorganisms confine their 
ravages almost exclusively to the heart; occasionally they are transmitted 
through the blood stream to distant parts of the body, where they may 
produce inflammatory infarcts. In the septic form, however, there is a 
bacteriemia of the same microorganisms which have produced the en- 
docarditis. The focus for the distribution of this general infection is in 
the ulcerated heart valves, from which the septic microorganisms are 
thrown into the blood stream and are generally distributed throughout 
the body, producing septic foci in distant organs; in this way the general 
clinical picture of septicopyemia is added to that of the existing en- 
docarditis. These cases are not necessarily septic or ulcerative from the 
start. Some years ago I reported three fatal cases of septic endocarditis, 
following ulcerative tonsillitis. In each instance the patient recovered 
from the first attack of endocarditis with damaged mitral valves, and 
months later secondary attacks of ulcerative tonsillitis were followed by 
endocarditis, which assumed the septic or ulcerative type and ended fa- 
tally. In one of these cases the necropsy showed ulceration of the mitral 
valve on both leaflets. 

The term malignant, used to describe these cases, is a misnomer, which 
has added confusion to this subject, as they are not malignant nor are 
they necessarily hopeless. Adams reports three recoveries in forty-seven 
cases collected from the literature (one of these was his own case), and 
the probabilities are that these figures do not represent the full percentage 
of recoveries. The important point to bear in mind is that the majority 
of these cases are not septic in the first attack and that subsequent at- 
tacks are produced by a secondary invasion from the same microorganisms 
which produced the first attack, but which, in the meantime, have been 



492 ACUTE ENDOCAKDITIS 

held quiescent in foci commonly located in the tonsils, but sometimes in 
the lungs, pelvis, and subcutaneous tissues. In any one of these attacks 
an ulcerative endocarditis may develop which may result in a general sep- 
ticopyemia. 

Symptomatology. — The symptoms of septic endocarditis are those of 
severe endocarditis plus a general septicopyema. One of the most im- 
portant diagnostic signs is the finding of septic organisms in the blood. 
These cases are characterized by high and variable temperatures, such as 
are seen in sepsis, the temperature commonly approaching or falling be- 
low the normal and rising to 104°, 105°, or 106° F. within the next 
twelve hours. There are great prostration, delirium, chilly sensations, and 
the body is frequently covered with a petechial rash. A high leukocyte 
count is present. These cases usually end fatally, but, under modern 
methods of treatment, the death rate promises to be less than it has 
formerly been. 

Diagnosis. — Accidental murmurs due to anemia, cardiac neuroses, and 
other causes may occur and are to be differentiated from the bruits pro- 
duced by endocarditis. The above-mentioned murmurs are commonly 
heard most distinctly at the base, are not transmitted to the axillary re- 
gion, and occur in non-febrile conditions. A relative insufficiency of the 
mitral valve may be caused by cardiac dilatation; the murmur thus pro- 
duced is associated with enlargement of the heart and displacement of 
the apex beat, and appears, as a rule, rather suddenly under conditions 
producing heart strain. The pericardial friction murmur rarely causes 
confusion; it is not transmitted, is intermittent in character, and its 
point of intensity is usually located at the base! 

Prognosis. — The prognosis in acute simple endocarditis, so far as life 
is concerned, is good. The great majority of these cases recover in three 
or four weeks. In a small minority there is complete recovery, but in 
the great majority of instances incompetency of the mitral valve occurs, 
which results in a leakage at the valve and a crippling of the heart, which 
is compensated for by cardiac hypertrophy. Secondary attacks of en- 
docarditis may result in further crippling of the heart and in the pro- 
duction of chronic valvular disease. In rare instances an ulcerative en- 
docarditis develops, associated with a septicopyemia; the prognosis in 
these cases is very bad, the great majority of them terminating fatally. 

Prophylaxis. — This comprehends the careful treatment of rheumatism 
and of all the acute infections. According to Forchheimer, the alkaline 
treatment of rheumatism diminishes the tendency to fibrin formation and 
thereby to endocarditis. In all of the acute infections, especially rheuma- 
tism, the heart must be carefully watched and the patient confined to bed 
during the acute stages of these diseases, and, in the event that symptoms 
develop referable to the heart, a longer period of absolute rest in bed 
must be insisted upon. The most important prophylactic treatment, how- 
ever, consists in the prevention of second and third attacks of endocarditis. 
If the primary attack was associated with chorea, rheumatic arthritis, or 



TREATMENT 493 

other symptoms indicating the rheumatic origin of the disease, then the 
subsequent life of the patient, at least for a number of years, should be 
carefully regulated to prevent second attacks of rheumatism, and he should 
take at intervals, especially during the winter months, courses of medical 
treatment which include the alkalies and salicylates. These medicines 
materially assist in warding off the second and third attacks. These pa- 
tients should spend their winters for a number of years in mild climates ; 
where this is impossible they should be protected by woolen underclothing 
and proper footwear from the cold, damp weather of the winter months. 
But the most important prophylactic measures in these cases are the re- 
moval of diseased tonsils and adenoids, and the daily disinfection of the 
throat and nose during the winter months with mild alkaline antiseptics. 
As previously noted, the lymphoid ring of the pharynx, which includes the 
tonsils and adenoids, is not only the common portal of entrance for the 
germs which produce endocarditis, but they offer a hiding place for them 
in the intervals between the attacks, which makes it possible for slight 
causes, such as exposure to damp cold, to set up a tonsillitis, to be followed 
by another attack of endocarditis. It is my belief that if the tonsils and 
adenoids in all these cases were removed following the first attack of 
endocarditis, and thereafter during the winter months the throat was daily 
douched with an alkaline antiseptic, relapsing endocarditis would be 
less common, and septic endocarditis could, in most instances, be pre- 
vented. 

Treatment. — The all-important part of the treatment is prolonged rest 
in bed, and unless this is carried out satisfactorily other curative measures 
are without avail. This implies that the child must be kept as quiet as 
possible, not allowed to sit up, and not permitted to get out of bed for 
any purpose whatever. The younger the child the more difficult it is to 
carry this out in a satisfactory manner. During the early acute inflam- 
matory stage an ice-bag or coils of cool running water should be applied 
over the heart; this is especially indicated when precordial pain and 
rapid heart action are present. In the less severe cases this application 
should be made at intervals during the day and under no conditions should 
it be used when it interferes with normal sleep, as sleep is almost, if not 
quite, as important as rest in bed. The surroundings should be as quiet 
as possible so as to avoid mental stimulation and nervous excitement. If 
the child be restless, nervous, and sleepless the bromides are indicated, 
and occasionally opiates may be necessary to secure proper rest; where 
these are indicated, a hypodermic injection of 1/20 to 1/50 of a grain of 
morphin may be given at bedtime. All sedative medication, however, 
should be discontinued as soon as possible and should be given only in 
those cases where the nervous irritation is markedly interfering with the 
rest of the child. The diet should be carefully selected to suit the wants 
of the individual child; milk, cereals, and eggs may form the basis of 
this diet during the acute stage. The bowels should be kept open by mild 
cathartic medication. If rheumatism be present, the salicylates should 



494 MYOCARDITIS AND ACUTE CARDIAC DILATATION 

be given until these symptoms are under control ; aspirin, salol, and winter- 
green sodium salicylate may be used, as recommended in the chapter on 
Rheumatism. When other internal medication is not indicated, bicarbonate 
of soda or some other alkali may be the routine treatment ; in older children 
two or three drops of tincture of nux vomica may be given with each dose 
of the alkali. In the treatment it should be remembered that all medicines 
that upset the stomach or interfere with the appetite do more harm than 
good. Where the heart is weak and the pulse irregular tincture of digitalis 
or strophanthus may be used in from 3 to 5-drop doses. In most cases 
of primary simple acute endocarditis cardiac stimulants, however, are not 
only unnecessary but are usually contraindicated. 

The important question to decide in every case is the length of time 
the patient should remain in bed; even in the mild cases one month is 
the minimum time. When the physician has decided that the patient 
has recovered sufficiently he may test the action of the heart by allowing 
him to sit up in bed, and, if no ill effects follow, within a few days he 
may be placed in a chair for a few hours during the day, and later may 
be allowed to walk across the room. In this way the patient, during con- 
valescence, should be carefully guarded against overexertion until the 
heart is able to do the work ordinarily required of it. If the patient be 
guided in this way to a satisfactory recovery, and future attacks of en- 
docarditis be prevented, the heart, in most instances, even though a loud 
mitral murmur persists, acquires a physiological competency which will 
enable the individual, throughout a long life, to follow many of the 
wage-earning vocations. 

Ulcerative Endocarditis. — This is the same as that of ordinary en- 
docarditis plus the treatment for septicopyemia. The antistreptococcic 
serum, and collargolum in the form of unguentum Crede should be used 
as outlined in the chapter on Scarlet Fever. A few cases have recovered 
under the use of these remedies, and, as they can do no harm, they should 
be given in every case. The treatment by homologous vaccines offers a 
chance for recovery, especially in the so-called Schottmueller's disease. 
From blood cultures the microorganism causing the trouble is isolated, and 
from this organism vaccines are made according to Wright's method. If 
these vaccines be administered early in the course of the disease good 
results may be hoped for in some cases. 



CHAPTER LVI 

MYOCARDITIS AND ACUTE CARDIAC DILATATION 

MYOCARDITIS 

Myocarditis is very common in childhood. It is usually produced by 
bacterial toxins and is therefore a common complication of the acute in- 
fections, especially diphtheria, scarlet fever, influenza, pneumonia, typhoid 



MYOCARDITIS 495 

fever, and whooping-cough. The toxins act directly upon the cardiac 
nerves and muscles, producing parenchymatous degenerations. The mus- 
cular fibers may show granular, hyalin and fatty degeneration, and under 
this change the heart muscle becomes weak, flaccid, and readily undergoes 
dilatation. 

Myocarditis may also be produced by the bacterial invasion of the 
organ along the line of the blood vessels and connective tissue ; in this form 
true inflammatory changes, involving especially the interstitial tissue, are 
produced. The most common offending organisms are streptococci, 
staphylococci and pneumococci, and the heart muscle itself may be in- 
filtrated with pus cells and may be the site of small abscesses. These cases 
commonly result from septic emboli carried to the heart, and may occur 
therefore as a complication of scarlet fever, diphtheria, ulcerative ton- 
sillitis, septicopyemia, osteomyelitis, and other diseases characterized by 
sepsis. In other cases the myocarditis may occur as a complication of 
endocarditis and pericarditis ; in many of these rheumatism is the exciting 
cause. 

Symptomatology. — The parenchymatous form of myocarditis, due to 
bacterial toxins, is of special interest to the physician because it is the 
most common form and the one in which his skill can be of the most 
value. Symptoms of parenchymatous myocarditis may develop at any 
time throughout the course of the above-named infections, but they occur 
more commonly during the stage of convalescence. An intermittent pulse 
and irregularity in the cardiac rhythm may be the first symptoms announc- 
ing the onset of myocarditis, and they are especially significant when 
they occur in diphtheria, scarlet fever, pneumonia, and severe forms of 
influenza. As the disease progresses apical systolic murmurs appear, the 
pulse becomes rapid, flickering and irregular, and the apex beat may be 
feeble and difficult to locate. As cardiac dilatation develops, the heart 
sounds may be indistinct, and other and more complicated cardiac mur- 
murs may occur, and the patient commonly complains of pain in the 
precordial region and suffers from nervous unrest. Pallor, cold extrem- 
ities, dyspnea, and cyanosis may be present. In diphtheria the above symp- 
toms, when associated with syncope and vomiting, are especially ominous 
and not infrequently presage death from myocardial insufficiency. In 
the milder cases, however, a modification of the above symptom group may 
continue for days or weeks until final recovery is established. The ir- 
regular and intermittent pulse sometimes continues for months or is 
readily developed on slight muscular exercise. 

Interstitial myocarditis presents the same symptom group as that 
above outlined for the parenchymatous form. The diagnosis therefore of 
this condition can only be inferred from the fact that it is preceded by 
or associated with endocarditis, pericarditis, or septic processes. In these 
latter cases a septic type of temperature is generally present. 

Prognosis. — The prognosis in the parenchymatous form is, as a rule, 
good and recovery, when it occurs, is usually complete. In the inter- 



496 MYOCARDITIS AND ACUTE CAEDIAC DILATATION 

stitial form the prognosis is bad. Most of the cases die, and in those that 
survive recovery is, as a rule, incomplete, the heart muscle being per- 
manently injured and frequently embarrassed by a coexisting endocardi- 
tis or pericarditis. 

ACUTE CARDIAC DILATATION 

Acute cardiac dilatation is commonly the result of a preceding myo- 
carditis, but, on the other hand, when it does occur as a primary condition 
it is almost always followed by more or less myocarditis. The two con- 
ditions are therefore inseparably associated in the medical mind, but, not- 
withstanding this, acute cardiac dilatation deserves separate consideration. 

Etiology. — Influenza and whooping-cough may cause this condition in 
infants and in young and delicate children. The dilatation of the heart 
in whooping-cough is largely produced by the strain on the cardiac muscle, 
which results from an overful heart attempting to force blood through 
the cardiac ostia under the greatly increased resistance which occurs dur- 
ing an acute paroxysm of this disease. I also believe with Forchheimer 
that the violent paroxysmal fits of coughing, ofttimes seen in influenza, 
may produce cardiac dilatation. The toxins of influenza may also weaken 
the heart muscle and thus predispose to dilatation. Acute dilatation may 
result in rapidly growing malnourished children, especially during the 
pubertic period, from the severe strain thrown upon the heart by bicycle 
riding, foot-racing, jumping-the-rope, and other forms of violent ex- 
ercise. It is most commonly seen, however, as a condition secondary to 
acute myocarditis, and is especially to be feared and watched for in the 
parenchymatous form of this disease, which is produced by the toxins 
of the acute infections. It also occurs with the failing compensation of 
chronic valvular disease and may occur as one of the earlier symptom 
groups of acute endocarditis. • 

Prognosis. — The prognosis depends largely upon the cause; where 
mechanical conditions are wholly or in great part responsible for the dila- 
tation recovery is, as a rule, rapid and complete. When acute toxic myo- 
carditis is the cause the prognosis is grave, but many of these cases end 
in complete recovery. When occurring as a symptom group of acute en- 
docarditis the prognosis, so far as the symptoms of dilatation are con- 
cerned, is on the whole favorable. When occurring as a symptom of 
failing compensation in chronic valvular disease the prognosis is grave, 
yet many of these cases have repeated attacks of acute dilatation from 
which they at least partially recover. 

Diagnosis. — The diagnosis of this condition must be made in connec- 
tion with the etiological factors which produce it. The physical signs in 
every instance are the same, but the general symptoms vary materially 
with the cause which has been operative in producing the dilatation. A 
rapid increase in the area of cardiac dullness with a marked displacement of 
the apex beat downwardly and outwardly always occurs. The cardiac dull- 



PROPHYLAXIS AXD TREATMENT 497 

ness may extend from outside the mammary line to the right of the 
sternum, and the apex, which is feeble and diffused, may be felt in the 
fifth or sixth interspace well outside the mammary line. A soft systolic 
murmur may sometimes be heard at the apex, and the second sound over 
the pulmonary area may be accentuated. This acute enlargement of the 
heart, made out by physical signs, occurring with any of the conditions 
above noted as being associated with the etiology of acute dilatation, may 
be accepted as proof of the existence of this condition. 

Acute dilatation is not always manifested by the same symptom group. 
Its presence, however, may be suspected when etiological conditions fa- 
vorable to its development are followed by sudden s}mcope, rapid breath- 
ing (tachypnea) and rapid and irregular heart action. In infants espe- 
cially a tendency to somnolence follows this acute prostration. From 
these alarming symptoms the child may gradually recover and present 
for a time the milder symptoms of cardiac distress above outlined under 
Acute Myocarditis. Repeated attacks of this kind may occur, somewhat 
milder in character, as the disease progresses to a favorable termination, 
or death may result at any time from complete myocardial insufficiency. 
In older children cardiac dilatation may produce a symptom group closely 
resembling angina pectoris. These cases, when associated with acute or 
chronic endocarditis, may present the clinical picture of angina sine dolore 
described by Musser, the absence of pain being due to the relief which the 
mitral insufficiency gives to the interventricular tension. In one such 
patient, nine years of age, whom I observed, the respirations reached 97 
per minute, were shallow in character, and not accompanied by cyanosis. 
During an attack she sat up in bed with body rigid, shoulders elevated, and 
head thrown back. Her eyes were fixed and staring; there was an ex- 
pression of fear and anxiety on her face, but when asked if she had pain 
she answered "no." The symptoms in this case were associated with an 
acute mitral insufficiency due to endocarditis. The angina symptoms were 
readily controlled by nitroglycerin and the patient made a satisfactory 
recovery, leaving the hospital with full compensation for a well-marked 
mitral insufficiency. 



PROPHYLAXIS AND TREATMENT 

Prophylaxis. — Rapidly growing anemic children should not be permitted 
to engage in forms of physical exercise which will overstrain the heart. 
This is especially important in children suffering from functional dis- 
turbances of this organ. In whooping-cough all violent exercise should 
be prohibited, and in those cases where the paroxysms are very severe 
and are associated with marked disturbance of the heart action it may 
be necessary to confine them to bed for a number of weeks until the dan- 
gers of acute dilatation and myocarditis are passed. In diphtheria, pneu- 
monia, and influenza it is of the greatest importance that the heart should 



498 CHRONIC VALVULAE DISEASE 

he carefully watched, so that with the first symptoms of cardiac distress 
the patient may be treated for myocarditis. 

Treatment. — This is much the same as in acute endocarditis. Absolute 
and prolonged rest should be insisted upon. The patient should not only 
be confined to bed but he should not be allowed to do anything for himself 
that can be done by others ; a fatal issue in many cases has been precipitated 
by the effort of sitting up in bed. During early convalescence great care 
must be used in determining the amount of exercise the patient may take 
with safety. An icebag over the precordial region is indicated if there 
be cardiac pain . and rapid heart action. Caffein sodium benzoate or 
salicylate (% to 2 grains), digitalis (2 to 5 drops of the tincture), or 
strychnin (1/100 to 1/200 of a grain) may be given, as indicated, at 
intervals of three or four hours. Camphor, dissolved in sterile oil, may be 
given hypodermically. In most cases one depends almost entirely upon 
the cautious use of tincture of digitalis or tincture of strophanthus ; these 
drugs may be given at four to six-hour intervals and in 2 to 5-minim doses, 
according to the age of the child. If the action of the heart is improved 
under their administration they should be cautiously continued. If the 
use of digitalis and strophanthus is not followed by good results caffein, 
strychnin, or camphor may be administered hypodermically. In some 
instances, where the nervous unrest is very marked, morphin, in 1/20 to 
1/50-grain doses, given hypodermically, acts very kindly and may be 
repeated as indicated. Alcohol in the form of good whiskey or brandy 
is of value. During convalescence iron and arsenic may be indicated. 

In the treatment of acute cardiac dilatation, the removal of four or 
five ounces of blood from the median cephalic vein may give great relief 
and tide the patient over the attack. The application of leeches over 
the region of the liver is also recommended. My own experience teaches 
me that nitroglycerin is preferable to bleeding; it is indicated when the 
heart is in severe distress and may be discontinued when the acute symp- 
toms threatening cardiac paralysis have passed away. 



CHAPTEE LVII 
CHRONIC VALVULAR DISEASE 

Chronic valvular disease is almost always due to endocarditis. This 
applies to the congenital as well as the acquired form. Not infrequently, 
however, the primary attack of endocarditis is overlooked, and the disease 
first comes under the observation of the physician in its chronic form; this 
is especially true in hospital practice. In most of these cases there is a 
history of a previous attack of acute rheumatism, or of some other acute 
disease, which leads to the belief that acute endocarditis occurred during 
that attack. 



MITRAL REGURGITATION 499 

The mitral valve is affected in about 90 per cent, of the cases, and in 
the great majority the lesion is that of mitral insufficiency. Mitral stenosis, 
however, may occur as an independent lesion, or insufficiency and stenosis 
of this valve may be associated. Aortic disease, as an independent lesion, 
is more common in boys than girls. It is rare in childhood; stenosis is 
more common than insufficiency. Arteriosclerosis and other causes of 
aortic disease in the adult are not present in the child. Aortic lesions, 
especially stenosis, occur more commonly with mitral disease than as in- 
dependent affections. Chronic disease of the pulmonary valves is very 
rare and usually congenital. 

Chronic endocarditis is rarely seen as early as the second or third 
year of life, but from this time on it occurs with increasing frequency 
throughout childhood. Following an acute attack of endocarditis, which 
has permanently damaged the valves, especially the mitral, the young and 
growing heart muscle of the child rapidly hypertrophies to the extent 
that the lesion is largely compensated. Under this compensation the 
heart is able to perform its ordinary physiological duties and the individual 
may live a useful and comparatively healthful life, provided the heart is 
not overstrained or subsequently damaged by a second or third attack 
of acute endocarditis. 

Mitral Regurgitation. — This is the condition found in the vast ma- 
jority of the cases of chronic valvular disease in childhood. The mitral 
valve is incompetent and with each systole of the ventricle a portion of the 
blood is forced back through the leaking valve into the left auricle; this 
results in dilatation of the auricle, and, to accomplish the increased work 
thrown upon them, both auricle and ventricle hypertrophy. If this re- 
sults in complete compensation the circulation is maintained, the right 
side of the heart is protected, and all goes well, the child suffering com- 
paratively little inconvenience from the lesion. 

Symptomatology. — Compensation, almost if not quite complete, is the 
condition usually found in the chronic mitral insufficiency of childhood. 
In these cases there is a tendency to shortness of breath, rapid heart 
action, and bronchial cough, which is greatly exaggerated by physical 
exercise. Well-marked anemia may also be present. In many instances 
the above symptoms are so slight as to be almost or quite overlooked, but 
the physical signs are very characteristic. The apex beat, which is dis- 
tinct and forceful, is found outside of the nipple line in the fifth inter- 
costal space. Auscultation reveals a blowing systolic murmur most in- 
tense at or near the apex, but very distinctly transmitted to the left below 
the axilla in the direction of the lower portion of the scapula. It is one 
of the peculiarities of this condition in childhood that this murmur may 
be heard almost as distinctly in the back, between the lower spine of the 
scapula and the vertebral column, as it is in front. The second sound of 
the heart is usually accentuated over the pulmonary area, but if it be 
sharply and intensely reduplicated it is an unfavorable sign, indicating 
a severe mitral lesion with increased blood pressure in the pulmonary 



500 



CHRONIC VALVULAR DISEASE 



artery. An increase in the size of the heart downward and to the left may 
be demonstrated both by percussion and by a radiograph. 

Mitral Stenosis. — Mitral stenosis is a much less common but a much 
more serious lesion in childhood than mitral insufficiency. It is usually 
caused by repeated attacks of a low grade of rheumatic endocarditis. The 
history of rheumatism elicited in these cases is of the milder and more 
chronic types, and in some cases it is entirely wanting. The disease is, 
as a rule, rather insidious in its onset, and, during its early stages, espe- 
cially in younger children, some of its characteristic physical signs may be 
absent. Jacobi has especially called attention to the fact that mitral 




Fig. 80. — Enlarged Heart from Mitral Regurgitation. (S. Lange.) 

stenosis may exist without the presence of a diastolic murmur. This con- 
dition is rare in early childhood, but is much more frequently seen after 
the tenth year. It may exist as an independent condition, or it may be 
associated with mitral regurgitation. Poynton and others note the fact 
that a systolic bruit may precede and then give way to a diastolic 
or presystolic bruit as mitral stenosis becomes well established. In mitral 
stenosis the auricle is called upon to force its blood stream through a con- 
tracted mitral opening, and, as a result, it undergoes dilatation and hyper- 
trophy. The blood is dammed back into the pulmonary circulation and 
the blood pressure in the pulmonary artery is greatly increased. Rapid 
and sometimes extensive hypertrophy of the right ventricle results. This 
hypertrophied right ventricle may continue for a long time to force suf- 



AORTIC STENOSIS 501 

fieient blood through the pulmonary circuit to supply the demands of the 
general circulation which is kept up by the left heart, but even under 
these favorable conditions the left ventricle does not receive enough blood 
to supply the general circulation, and, as a result, this ventricle, instead 
of undergoing hypertrophy, as in mitral regurgitation, may become smaller 
or remain the same size, so that the apex beat in this condition is not 
displaced. With failing compensation the right ventricle becomes dilated 
and the general symptoms of cardiac insufficiency develop. 

Symptomatology. — This condition is commonly insidious in its onset. 
Lack of development, anemia, irritable heart, and, as Chapin has observed, 
pain in the region of the heart and dyspnea on exercising are usually 
present. 

On auscultation a characteristic rough, presystolic murmur immediately 
precedes and is sharply terminated by a snapping first sound at the apex. 
Its point of greatest intensity is over the apex of the heart, which is found 
in its normal position. The murmur, unlike that of mitral regurgitation, 
is not transmitted toward the axillary line. The pulmonic second sound 
is accentuated. Increase in the size of the heart, as shown by percussion 
or by a radiograph, may be marked, and extends upward and to the right 
beyond the sternum. A presystolic thrill may be felt over the heart. 
Where mitral insufficiency- is associated with mitral stenosis, as it is in 
a large percentage of these cases, there is a combination of the physical 
signs of the two conditions, with a double murmur at the apex, the diastolic 
immediately preceding the systolic murmur. 

Aortic Regurgitation. — Aortic regurgitation is rare, but is seen in later 
childhood. Its characteristic sign is a diastolic murmur, having its point 
of maximum intensity in the second, third, or fourth intercostal space 
near the sternum. It is transmitted downward along the sternum. The 
heart is greatly enlarged, due to hypertrophy of the left ventricle. The 
apex beat is displaced downward and outward, and the cardiac dullness is 
increased in the same direction. The greatly hypertrophied left ventricle 
drives with great force the blood stream into the aorta and with the recoil 
of this stream, due to the defective valve, we have the "water-hammer 
pulse," characteristic of this condition. This is the most serious of 
cardiac lesions, usually resulting fatally before or about the time of puberty. 
The symptoms of cardiac insufficiency are much more commonly present 
than in mitral lesions. Pallor, stunted growth, rapid, irregular pulse, 
dyspnea, and cyanosis are common, and, with the breaking down of the 
partial compensation, the symptoms of gradual cardiac failure appear. 
Sudden death may occur in these cases. 

Aortic Stenosis. — This is also a rare condition and is not uncommonly 
associated with aortic regurgitation. The characteristic bruit is a harsh, 
systolic murmur heard most distinctly in the second right interspace near 
the sternum and is transmitted upward into the large arteries of the neck. 
The hand on the chest feels a distinct systolic thrill. The left ventricle 
is hypertrophied, the apex beat is displaced downward and outward, and 



502 CHKONIC VALVULAE DISEASE 

an increased dullness may be outlined in the same directions. The symp- 
toms of cardiac incapacity are the same as those above noted in aortic 
regurgitation. 

Tricuspid Regurgitation. — Tricuspid regurgitation occurs in congenital 
conditions and as a late development of failing compensation in mitral 
and aortic disease. Apart from these conditions it is almost unknown 
in childhood. It is characterized by a systolic murmur heard over the 
lower portion of the sternum. 

Failing Compensation. — Failing compensation may result from the se- 
riousness of the valve lesion itself, from too severe physical strain thrown 
upon the heart, or from repeated attacks of endocarditis. In this condition 
the blood is dammed back into the pulmonary circulation, producing a 
great increase in the blood pressure of the pulmonary artery, which causes 
a sharp, quick closing of this valve, reduplication of the second sound, and 
later incompetency of the tricuspid valve. It will thus be seen that the 
giving way of the heart in chronic valvular disease may first be indicated 
by a marked accentuation and reduplication of the second sound over the 
pulmonary valve, and later by a marked dilatation of the heart with a 
displacement of the apex beat downward and outward. This great increase 
in the size of the heart, which occurs in failing compensation, results in 
the development of other murmurs, associated with the aortic, and possibly 
the pulmonary, valves. The great enlargement of the heart in this con- 
dition may be seen in a radiograph, or made out by percussion. Asso- 
ciated with the great increase in the area of cardiac dullness, the apex 
beat is diffuse and the vibrations of the struggling heart may be seen and 
felt in the intercostal spaces. In these cases the pulse beat is irregular 
and rapid; dyspnea, orthopnea and cyanosis are present. The legs may 
be slightly swollen, and in some instances a general anasarca may de- 
velop, the abdominal cavity being filled with fluid. This gradual failure 
of compensation, resulting in death, is unusual in childhood. It much 
more commonly occurs at or after puberty. 

Prognosis of Chronic Valvular Disease. — The prognosis of chronic val- 
vular disease depends upon the following conditions: first, the valve 
affected; second, the extent of the valvular lesion; third, the complete- 
ness of the resulting compensation; fourth, the possibility of preventing 
recurring attacks of endocarditis; fifth, the proper regulation of the life 
of the child, so that he may have proper exercise without throwing se- 
vere strain at any time upon the heart muscle. 

The prognosis is best in uncomplicated mitral regurgitation. In 
many of these cases compensation may be so complete that the heart is 
physiologically competent to carry on the circulation under the ordinary 
conditions of life, so that these individuals may be useful members of a 
community throughout a long life. In mitral stenosis the prognosis is 
usually not so good, and there is more danger that the heart, even in the 
favorable cases, may show a failing compensation at or about puberty. In 
aortic disease the prognosis is, as a rule, bad, as few of these cases live to 



TREATMENT OF CHRONIC VALVULAR DISEASE 503 

be useful members of a community; they commonly die in later child- 
hood or about puberty. Where more than one valve is affected the gravity 
of the prognosis is greatly increased. 

The extent of the valvular lesion can commonly be estimated by the 
displacement of the apex beat, the degree of cardiac hypertrophy and 
dilatation, and by symptoms pointing to increased blood pressure in the 
pulmonary artery. The gravity of the prognosis is in direct proportion 
to the severity of these signs and symptoms. 

When complete compensation has been established and all symptoms 
of cardiac irritation have subsided and the child is able to resume his 
ordinary vocations without cardiac distress, the prognosis is good, and 
it is correspondingly bad when, after proper and prolonged treatment, 
complete compensation cannot be established. 

Treatment of Chronic Valvular Disease. — The most important factor in 
the prognosis, in those cases in which compensation has been established, 
is the possibility or probability of preventing recurring attacks of endo- 
carditis. In accomplishing this end the cause of the previous endocarditis 
must be taken into* consideration. In the great majority of these cases 
rheumatism is the exciting factor, and the treatment, therefore, largely 
consists in the prevention of subsequent attacks. These children should, 
if possible, for a number of years avoid the cold, damp, changeable weather 
which prevails during the winter months in our middle and northern 
States, by spending the months of January, February and March in a 
warm, dry, and equable climate. Those children that are compelled to 
remain under unfavorable climatic conditions should, during the winter 
months, wear woolen underclothing, sleep in well-ventilated apartments, 
and in suitable weather spend a great portion of the day out of doors, 
being always careful to avoid damp cold. It is especially important that 
they should be properly shod so that their feet may be always dry and 
warm. Above all, they should not be allowed to go to school or be closely 
housed with other children where the air is bad and contagions are pres- 
ent. All diseases that in any way involve the throat and respiratory pas- 
sages are especially dangerous, and every effort should therefore be made 
to protect them from contagious diseases, especially influenza and ton- 
sillitis. 

In the treatment of chronic valvular heart disease it is especially im- 
portant to remember the close relationship which exists in many of these 
cases between tonsillitis and recurring endocarditis. Every child with a 
compensated heart lesion should have the tonsils and other lymphoid tissues 
in his throat and pharynx carefully inspected. If the tonsils and adenoids 
be enlarged or diseased, they should be removed during the spring or sum- 
mer months, and the adenoid ring, of which they are a part, should there- 
after be kept in as healthful a condition as possible, to prevent the entrance 
of the contagion of rheumatism and other acute infections. 

Avoidance of heart strain is a most important measure in preventing 
the breaking down of compensation. To accomplish this the child must 



504 CHRONIC VALVULAR DISEASE 

be under such proper medical supervision that he may have prescribed for 
him the exercise necessary to the development of the heart without pro- 
ducing cardiac strain. The careful medical observer can, as a rule, tell 
the child what he should do in the way of physical exercise, but he is not 
always so fortunate as to have his directions carefully followed. The heed- 
lessness of childhood and ofttimes the carelessness of parents are factors 
over which he has no control. The importance of this subject demands 
that he should give explicit directions, and not vague statements, with 
reference to exercise, and that he should impress upon the parents, as 
well as the child, the absolute necessity of following directions. No 
general rule as to the kind of sports and the character of exercise can be 
made which will apply to all cases of heart disease; each case must be 
studied individually and prescribed for accordingly. If the lesion be a 
mitral one and complete compensation, without great enlargement of the 
heart, has followed, it is probable that a return to the ordinary sports of 
childhood may be gradually accomplished without injury to the heart. 
Golf, horseback-riding, swimming, a moderate amount of ball-playing may 
in time be safely indulged in, but at no time, even in these favorable cases, 
should tennis playing, hard bicycle riding or endurance contests of any 
kind, such as running, rowing or rope jumping, be permitted. It should 
be remembered, moreover, that it is only the most favorable cases of 
fully compensated mitral insufficiency that can be allowed this freedom 
in outdoor sports. In most of the cases the exercise should be much more 
restricted throughout childhood, and the parents as well as the patients 
should be told that the greatest danger of failing compensation occurs at 
or about puberty, and that for this reason the heart muscle must be kept 
in as good a condition as possible, by gentle exercise and by avoiding heart 
strain, that this critical period may be safely passed. 

The general regulation of the life of the child is important. Nutrition 
must be especially looked to, by giving suitable food at regular intervals. 
An excess of sweets is to be avoided ; sugar in the form of candy, confec- 
tions, and pastry may do much harm. The diet should be a general one 
consisting of vegetables, eggs, milk, cereals, fruit, and a moderate amount 
of meat. Disturbances of digestion, and constipation, should be carefully 
guarded against. Severe nervous and mental strain, such as may be asso- 
ciated with school work, is to be avoided ; these children are easily excited, 
and their nervous systems readily break down from overwork and excite- 
ment. They require more rest than the normal child; they should go 
to bed early, and during the day, if there be the least sensation of 
fatigue, they should be required to lie down after their midday meals ; this 
applies even to those cases where compensation is apparently complete. 

Systematic medical treatment may be important. This applies espe- 
cially to those cases in which rheumatism is the etiological factor. It 
consists largely in the giving of alkalies and the salicylates during the 
winter months for a number of years following the initial attack of endo- 
carditis. Bicarbonate, or benzoate, of soda, 5 to 10 grains, may be com- 






TREATMENT OF CHRONIC VALVULAR DISEASE 505 

binecl with (wintergreen) salicylate of soda, 3 to 5 grains, put up in a 
palatable vehicle. This should be given for one week in every month, and 
during the remaining time the child should drink alkaline waters. 

If anemia is present, iron, arsenic, and cod-liver oil may be of benefit, 
but the presence of this symptom usually indicates an incomplete com- 
pensation, or the occurrence of some complicating disease, and in either 
event its cause demands careful study, and the resulting treatment will 
depend upon the cause. If well-marked anemia occurs, the child should 
be put to bed the greater portion of the day and night in the fresh air 
out of doors, or with the bedroom windows wide open; this, with careful 
feeding, and the above-named tonics, will produce a rapid improvement in 
the blood state. 

Treatment of Incomplete or Failing Compensation. — In the foregoing 
sketch of the treatment of chronic heart disease with full compensation, no 
mention has been made of the use of digitalis or other heart tonics, be- 
cause they are not indicated when compensation is complete. Great harm 
may be done by the unnecessary administration of these drugs to a patient 
whose heart muscle is fully capable of doing its work; a heart murmur is, 
therefore, not always an indication for heart stimulants. When the symp- 
toms of incomplete or failing compensation are present, these heart stim- 
ulants, properly administered, in association with rest in bed, are, as a 
rule, necessar} T , but above all I wish to impress the fact that in these cases 
rest in bed should be the first order, and heart stimulants the second. It 
is a fatal mistake to try to overcome the rapid, irregular pulse and short- 
ness of breath of children with chronic heart disease, by giving them 
digitalis and allowing them to remain upon their feet. Rest in bed is 
the all-important remedy, just as it is in acute cardiac affections. During 
the time they are confined to bed, and for some time thereafter, heart 
stimulants are of value. The best of these is digitalis; it may be given 
in the form of the tincture, from 3 to 6 drops, depending upon the age 
of the child; care, however, being taken that its administration does not 
disturb the stomach. The fat-free tincture may, as a rule, be adminis- 
tered in essence of pepsin over a long period of time without producing 
gastric disturbance. In some cases it may be necessary to substitute tea- 
spoonful doses of the fresh infusion of digitalis, or from 3- to 5-drop doses 
of the tincture of strophanthus. The latter remedy, while not as reliable 
as digitalis in bringing about compensation, is of much more value in the 
child than it is in the adult, and serves a very useful purpose in those 
cases where digitalis disturbs the stomach. It should also be remembered 
that the action of digitalis is cumulative, and for this reason its adminis- 
tration should he interrupted from time to time, to be again resumed when 
the heart begins to flag. Sulphate of strychnin, 1/100 to 1/200 of a grain, 
may be of value as a respiratory, cardiac and general tonic, if given over 
a considerable period of time. In those cases that do not respond fullv 
to the rest and digitalis treatment, and which stop slightly short of full 
compensation, the home administration of the Nauheim bath, which is 



506 FUNCTIONAL CAEDIAC DISORDERS 

of such value in the treatment of myocardial insufficiency in the adult, may 
be tried. These baths are especially applicable in older children, and the 
rules governing their administration should be the same as those outlined 
in the treatment of myocardial insufficiency in the adult. In those unusual 
cases of chronic myocardial insufficiency associated with well-marked 
dropsy the amount of fluid taken by the patient should be restricted, if 
possible, to one quart in the twenty-four hours. In these cases all the fluid 
taken should be carefully estimated, so that the sum of all the water and 
liquid foods should not exceed this amount. 

If marked ascites is present, paracentesis gives great relief, and is fol- 
lowed by improvement in the action of the heart. In this operation the 
same precaution should be taken as in the adult, the fluid being slowly 
withdrawn and the abdominal wall subsequently firmly supported by an 
abdominal bandage. 



CHAPTER LVIII 

FUNCTIONAL CARDIAC DISORDERS 

Disturbances in the rate and rhythm of the heart's action, not asso- 
ciated with inflammatory disease of this organ, are common. The child, 
by reason of the immaturity and instability (lack of inhibition) of its 
nervous system, is normally predisposed to functional disorders of the 
heart, and this predisposition may be greatly increased by a neurotic in- 
heritance and by anemia and general malnutrition. In children of this 
type the cardiac nervous mechanism is easily disturbed by reflex and toxic 
factors, such as are commonly present in gastrointestinal disturbances 
and the acute infections. 

Arrhythmia. — Arrhythmia, or irregularity in the heart's action, is com- 
mon in infancy and childhood, and has, as a rule, little pathological sig- 
nificance. It may occur in nervous children even during sleep, from slight 
or unknown exciting causes. It may result from fright, anger or nervous 
excitement of any kind; a cold bath, severe exercise, slight fevers, and 
bacterial intoxications may produce more or less irregularity in the 
rhythm of the heart's action ; a variation of 20 to 30 beats may occur within 
a few minutes without special pathological significance. Palpitation of 
the heart, associated with pain in the side and shortness of breath on 
exercise, is not uncommon in nervous, anemic, rapidly growing children. 
As elsewhere noted, it is not improbable that the explanation for the asso- 
ciation of certain cardiac neuroses in older children with their rapid 
growth may be due to the excessive action of the thyroid gland during 
this period of life, the increased function of this gland being responsible 
in part, at least, for both the rapid growth and the cardiac irritability. 

Paroxysmal Tachycardia. — Paroxysmal tachycardia may occur in older 
children. These attacks are commonly produced by auto- or intestinal 



FUNCTIONAL HEAET MUEMUES 507 

toxins. They are not infrequently associated with constipation, coated 
tongue, bad odor to the breath, headache, perspiration, and sometimes with 
an elevation of temperature. A gouty or migrainous diathesis may be 
etiologically related to these cases, and masturbation may be a predis- 
posing factor. I have seen this symptom group associated with attacks 
of recurrent coryza. 

Bradycardia. — Bradycardia, or slow heart action, may also occur as a 
purely reflex disorder in nervous, malnourished, neurotic children. The 
exciting cause in these cases is commonly of intestinal origin. The asso- 
ciation, however, of bradycardia and arrhythmia occurring in certain of the 
acute infections, such as diphtheria and influenza, may be of ominous sig- 
nificance, denoting a toxic myocarditis rather than a simple functional 
disturbance. 

Functional Heart Murmurs. — Accidental and functional heart murmurs 
are very common in early, as well as in late, childhood. They very often 
have no apparent pathological significance ; they may be hemic, due to pro- 
found anemia; they may be myocardial, resulting from malnutrition, irri- 
tation, defective innervation, or inflammation of the heart muscles, or they 
may be cardiopulmonary in character. 

The most common accidental murmur is the "late systolic pulmonary 
murmur," spoken of by many writers and carefully described by Hamill 
and le Boutillier. It is soft-blowing in character, moderately high pitched, 
and is continuous with, or immediately follows, the first sound. This sys- 
tolic murmur has its point of maximum intensity in the second left inter- 
space close to the sternal border, but it may be distinctly heard lower down 
in the third and fourth spaces between the midclavicular and parasternal 
lines. It is best heard in the recumbent position, at the end of inspira- 
tion; it may entirely disappear upon forced inspiration, and is exaggerated 
by exercise. The position of the apex beat of the heart is not altered, 
and the area of heart dullness is not increased. It may be transmitted to 
the vessels in the neck and is usually associated with a venous hum over 
both sides of the neck. Hamill says that this murmur has no definite 
pathological significance. It may occur in the absence of anemia, but 
"unquestionably the conditions giving rise to this murmur are frequently 
associated with anemia." Ltithje, Hamill, and le Boutillier found this 
murmur in over 60 per cent, of institutional children under five years of 
age; it is therefore of the greatest importance that it should be carefully 
differentiated from bruits produced by organic disease of the heart. In 
making this differentiation it should be remembered that it is not con- 
genital and that it is aggravated by the recumbent posture, is loudest at 
the end of expiration, and commonly disappears when the lungs are fully 
inflated. The location of the murmur, the normal position of the apex 
beat, and the normal area of cardiac dullness are most important. 

Forchheimer has especially emphasized the fact that mild forms of 
acute myocarditis occurring in scarlet fever, diphtheria, typhoid, rheu- 
matic fever, variola, gonorrhea, septicopyemia, acute nephritis, and other 



508 FUNCTIONAL CARDIAC DISORDERS 

acute infections characterized by fever may produce transient, systolic, 
apical bruits which disappear when the myocardium recovers from the 
irritation produced by the acute toxemia. Systolic bruits from this cause 
have their point of greatest intensity at the apex, and are, as a rule, not 
transmitted to the axillary line. It is most important to keep in mind the 
conditions under which this character of heart bruit may occur, and it is 
always wise in these cases to withhold a definite prognosis until the condi- 
tion of the heart may be studied after the acute intoxication has disap- 
peared, since in many of these cases it will be found that what seemed a 
simple myocardial bruit is later found to be due to a true endocarditis. 
This type of cardiac murmur is not infrequently associated with chorea. 

The cardiopulmonary murmur produced by the movement of the air 
in that portion of the lung which is in direct contact with the heart is 
systolic in time and heard with maximum intensity at the apex along the 
left border of the heart. It is inconstant, heard loudest at the end of 
expiration, and is comparatively infrequent, especially in the young child. 

Venous murmurs occur both in infancy and childhood. They are most 
commonly heard over the large veins of the neck; they may be associated 
with anemia, glandular tuberculosis, enlarged thymus, rickets, and other 
malnutritions. The venous murmur described by Eustace Smith has long 
been recognized; it is produced by the pressure of enlarged glands upon 
the innominate veins, and is made much more distinct by throwing the 
head of the child backward; by this movement the enlarged glands, back 
of the veins, push them forward and compress them against the manubrium 
sterni. 

In the diagnosis of functional murmurs, it is important to remember 
that diastolic bruits are nearly always organic, and that, as Forchheimer 
says, "The accentuation of the second pulmonary sound is of little value 
for diagnostic purposes, first, because it so frequently occurs in children 
who have no heart disease, and, secondly, it exists in both organic and 
functional valvular conditions in older children." 

Prognosis of Functional Cardiac Disorders. — The prognosis in purely 
functional endocardial murmurs is good. The prognosis in venous mur- 
murs will depend upon the exciting cause. 

Treatment. — Severe exercise is to be prohibited; moderate exercise out 
of doors is of great value in restoring the tone of the heart muscle. The 
malnutrition, anemia and nervousness in these cases is to be combated by 
living and sleeping out of doors; by a carefully regulated diet of easily 
digested foods, including milk, eggs and meat ; and by such tonics as iron, 
arsenic and cod-liver oil. The individual case in every instance must be 
studied to determine the important underlying causes of the cardiac neu- 
rosis. In many instances constipation and gastrointestinal toxemia are 
to be carefully combated. In others the anemia requires treatment. In 
others some profound constitutional disturbance, such as tuberculosis, 
may have to be combated. While the curative treatment is being directed 
toward the removal of the underlying causes, it may be necessary for a time 



PATHOLOGY 509 

to give nerve sedatives, such as the bromides or valerian, and in rare in- 
stances digitalis may be demanded. 



CHAPTER LIX 

PEEICAEDITIS 

Pericarditis is an inflammation of the pericardium, which in childhood 
is usually associated with endocarditis, the two conditions having very 
much the same etiological factors. 

Etiology. — It may occur in utero, is not uncommon during the first 
year of life, and is met with in increasing frequency throughout child- 
hood. Acute rheumatism is the most common direct etiological factor; 
rheumatic polyarthritis and chorea are associated with a large percentage 
of the cases. Scarlet fever, sepsis, pneumonia, tuberculosis, and other acute 
and chronic infections may be exciting causes. Pericarditis may be pro- 
duced by the transference of the infectious material through the blood or 
lymph channels, or by direct infection from contiguous diseased struc- 
tures in the lungs, pleura or heart itself. Hochsinger says it is a pe- 
culiarity of the pericarditis of childhood that in infancy it depends chiefly 
upon pyemic infection, in early childhood mainly upon the spread of in- 
flammatory processes, and in later childhood upon rheumatism, which may 
be associated with chorea; the exudate, therefore, in infancy is usually 
purulent; in early childhood generally serofibrinous, and in later child- 
hood almost always purely fibrinous. The microorganisms most common- 
ly found are pneumococci, streptococci, staphylococci, tubercle, colon and 
pyocyaneus bacilli. 

Pathology. — The pathological anatomy is similar to that found' in the 
adult. There are three varieties. The fibrinous variety is characterized 
by a fibrinous exudate covering both the visceral and parietal pericardium, 
the rough surfaces of which are rubbed together by the action of the heart, 
producing the to-and-fro friction rub. The serofibrinous variety is the 
same as the above, with the addition of a serous exudate, which as it col- 
lects gradually separates the roughened surfaces of the pericardium; in 
some instances there may be an enormous dilatation of the sac. These two 
varieties are commonly but different phases of the same pathological pro- 
cess, and rheumatism is the all-important etiological factor. In the puru- 
lent variety the exudate is composed of pus or seropus, which may be 
tinged with blood. In some of these cases miliary tubercles may infiltrate 
the pericardium, in others the disease may be associated with pneumonia 
or purulent pleurisy. Again, a simple serofibrinous pericarditis may be 
converted into the purulent form. Endocarditis and myocarditis are very 
commonly associated with pericarditis. With the absorption of the fluid 
and the subsidence of the inflammation, adhesions may occur between the 
pericardial layers, which greatly cripple the action of the heart. E a rely in 



510 PEEICAEDITIS 

mild forms of pericarditis, due to rheumatism, there may be complete 
restoration of the parts. 

Symptomatology. — Pericarditis is frequently a very obscure condition, 
and its recognition is ofttimes difficult ; in many instances the diagnosis is 
made on the post-mortem table. Mistakes in diagnosis may be due to the 
fact that there is a complicating endocarditis or myocarditis, and the symp- 
tom group is thereby confused, but in most instances they are due to lack 
of careful physical examination. The general symptoms, while not char- 
acteristic, are important and suggestive. Fever is nearly always present; 
in the fibrinous and serofibrinous varieties it may not rise above 101° or 
102 °F. In the purulent form it is remittent or intermittent in character, 
running as high as 104° or 105 °F., and perhaps falling within the day to 
normal or below; this type of temperature, associated with other signs of 
cardiac disease, commonly means either a septic endo- or pericarditis, and 
the physical signs must make the differentiation. In pericarditis there 
may be and commonly is palpitation, precordial pain and more or less 
marked dyspnea, sometimes amounting to orthopnea; the pulse is rapid, 
frequently reaching 130 or 160, and not infrequently cyanosis and marked 
acceleration of the respiratory movements are present. The above symptom 
group should suggest pericarditis, rather than a simple endocarditis; the 
same symptom group, however, may be present in myocarditis with acute 
dilatation. It should be remembered, however, that not every case of 
pericarditis is marked by the above symptoms of cardiac distress; in some 
instances the disease is very insidious in its onset, and may not be suspected 
until physical signs reveal its presence. 

Physical Signs. — A to-and-fro friction rub, synchronous with the 
heart's action, is the most typical sign of this disease. In the beginning 
it is usually soft and later becomes hard and grating; it is commonly 
heard best over the base, and firm pressure with the stethoscope may make 
it more distinct. Change of position may cause it to vary in intensity; 
it is least distinct with the child lying upon its back, and is commonly 
exaggerated when the child sits up or leans forward. In most instances 
it lacks constancy and does not continue to be synchronous with the to- 
and-fro action of the heart; it may be heard only during systole, or com- 
plete intermittency may occur. As effusion occurs it becomes less and less 
distinct, finally disappearing altogether as the layers of the pericardium are 
separated. In these cases the rub may sometimes be again discovered and 
the apex beat again be felt by placing the child in the knee-elbow position. 
With the disappearance of the friction sound, due to the increase of exu- 
date in serous and purulent pericarditis, the heart sounds are muffled, the 
apex beat becomes fainter, more diffused and may entirely disappear. 
With the absorption of the exudate, the heart sounds again become more 
distinct, the friction rub returns to remain, for a time, until convalescence 
is fully established and recovery has resulted either in complete absorption 
of the fibrinous exudate or in adhesions between the pericardial layers. 

Where the pericardial effusion is great, inspection may reveal a bulging 



DIAGNOSIS 511 

over the cardiac area, and percussion shows a very great increase of the 
cardiac dullness, which may extend as high as the second rib, an inch to 
the left of the sternum, curving from that point, well outside the nipple 
line and normal apex beat, as low as the sixth or seventh rib. To the 
right the dullness may extend 2 cm. or more beyond the sternum, and, con- 
tinuing downward, become continuous with the liver dullness. The out- 
lines of the distended pericardial sac are clearly shown by radiography. 



Fig. 81. — Pericarditis with Effusion. (S. Lange.) 

In fatal cases the anemia deepens to a marked pallor, the dyspnea 
becomes an orthopnea, the cardiac pain is more marked, the patient is rest- 
less, sleepless, and vomiting occurs. The area of cardiac dullness may 
increase enormously, the liver becomes enlarged, the pleura fills with fluid, 
the urine is scant and albuminous, the pulse is rapid, irregular and flicker- 
ing. Somnolence and coma may end the scene. 

Diagnosis. — There should be little difficulty in differentiating endo- 
carditis from pericarditis, except in those cases where the two conditions 
occur at the same time. In endocarditis the physical signs are constant 
and little influenced from day to day by changes in the condition of the 
heart, while in pericarditis the variability in the physical signs, from day 
to day, is noteworthy. The murmurs in these two conditions differ in their 
character, location and point of intensity, and differ especially in the fact 
that the murmur of endocarditis is transmitted, while the friction rub of 
pericarditis is not conducted, but is confined largely to the base of the 
heart and always to the pericardial region. The differential diagnosis, 
however, between pericardial effusion and acute dilatation of the heart is 
ofttimes a matter of great difficulty. The pericardial rub being absent, 
both conditions may present the marked increase in the area of cardiac 
34 



512 PERICARDITIS 

dullness, with the symptoms of cardiac distress. In acute dilatation, how- 
ever, these symptoms appear more rapidly, and in this condition also, 
palpation over the cardiac area reveals a cardiac thrill, and the apex beat, 
while faint and diffused, can readily be located by placing the patient in 
the knee-elbow position. 

Prognosis and Course. — The prognosis in pericarditis varies greatly with 
the individual case. The purulent cases with a septic temperature curve 
are, as a rule, fatal; a small percentage may recover if the pericardial 
sac is opened and carefully drained. In non-purulent pericarditis the 
prognosis, so far as life is concerned, is good, but in most of these cases 
the heart is permanently crippled by extensive adhesions. On the whole, 
therefore, it should be recognized that pericarditis of any form is a very 
serious disease, and that, while complete recovery may occur in a few of 
the mild cases, it is not to be expected. From the standpoint of etiology 
the pericarditis, associated with acute rheumatism and chorea, has a much 
more favorable prognosis than that produced by or associated with other 
infections. 

The duration of the acute symptoms may vary from one week in the 
mild, to many weeks in the severe, cases ; in the average, the physical signs 
run their course in about three weeks, but there is a long period of weeks, 
and sometimes months, during which the heart makes a slow, and in the 
majority of instances, only partial, recovery. 

Treatment. — The prophylactic treatment of pericarditis is the same 
as that of endocarditis. The child should be protected from rheumatism, 
and second attacks of this disease should be prevented if possible. Diseased 
tonsils and adenoids should be removed in all children who have suffered 
from one attack of rheumatism. When rheumatic symptoms occur, the 
child should be placed in bed, the disease carefully treated, and the heart 
watched for evidence of acute inflammation. 

Treatment of the Attack. — Absolute rest in bed is to be insisted 
upon throughout the acute symptoms ; the patient during this time should 
do nothing for himself that can be done by others. Following this, "the 
rest-in-bed" treatment, somewhat modified to suit the exigencies of the 
case, should be continued until the heart has sufficiently recovered its 
physiological competency to permit the patient to get out of bed without 
producing symptoms of heart strain. His diet should be simple, nutritious 
and suited to his digestive capacity; milk, eggs and cereals are to be recom- 
mended. If rheumatism be present, it should be carefully treated as noted 
in the chapter on that disease. The antirheumatic treatment, however, 
should not be given after the acute rheumatic symptoms have disappeared, 
as it exercises no controlling influence over the inflammation of the peri- 
cardium. An ice-bag should be applied to the pericardial region and kept 
there the greater portion of the time, until the acute symptoms have com- 
menced to subside. The ice-bag reduces the temperature, quiets the action 
of the heart and probably modifies the severity of the pericardial inflam- 
mation. Blisters and counterirritants over the region of the heart do more 



CHEOXIC PEEICAEDITIS WITH ADHESIONS 513 

harm than good. In chronic pericarditis 1 drachm of tincture of iodin, 
mixed with 1 ounce of anhydrous lanolin, may be used as an inunction 
over the cardiac region. Iodin given in this form is rapidly absorbed, and 
may possibly have some influence in promoting absorption. Morphin in 
from 1/10- to 1/50-grain doses may be given hypodermically to relieve 
pain; this is only necessary where the cardiac distress is very marked. If 
bromid of soda in 5- or 10-grain doses relieves the nervous irritability 
and cardiac distress, it may be used instead of morphin. Where the heart 
is weak and myocardial insufficiency threatens, strychnin, digitalis and whis- 
key should be given. The digitalis, especially in many of these cases, serves 
a useful purpose, but its action should be carefully watched, and if its 
administration is followed by an improvement in the action of the heart, 
it should be continued. Whiskey and strychnin, if they do not disturb 
the stomach, can do no harm and may. therefore, be given for days at a 
time, where cardiac and respiratory stimulation are necessary. 

The treatment of pericarditis with marked effusion calls upon the 
physician to decide the difficult question as to whether an attempt shall 
be made to remove the fluid either by aspiration or by radical surgical meas- 
ures. In the opinion of Botch, "Paracentesis of the pericardium should 
unhesitatingly be performed when life is in danger from undue distention 
of the pericardial sac. A small aspirating trochar should be used. Opin- 
ions differ widely as to the best point of puncture. Inasmuch as the 
heart, when an effusion is present, remains in its usual position and does 
not, even when much enlarged, impinge on the fifth right interspace, and 
as the effusion, even when in so small an amount as 100 c. c, is found at 
that point, I consider it more rational to choose the fifth right interspace, 
4 cm. (iy 2 inches) outside the right border of the sternum, as the point 
for tapping, thus avoiding all danger of injuring the heart. At this point 
the right internal mammary artery will not be injured. Another place to 
aspirate, recommended by Osier, is the left fourth interspace, either close 
to the sternal margin or 2.5 cm. (1 inch) from it, in order to avoid 
wounding the internal mammary artery. The left fifth interspace, 3.75 
cm. (iy 2 inches) from the sternal border, may also be taken for the point 
of puncture." After introducing the needle as above directed, such fluid 
as will readily flow through the trochar should be allowed to drain away 
very slowly. And if this operation reveals a purulent pericarditis, the case 
should be referred to the surgeon for operative treatment, since these 
cases are practically hopeless under any other mode of treatment. In 
properly selected cases, especially in older children, exsection of the rib, 
and the opening and free drainage of the pericardial sac, gives to the 
patient almost the only chance he has for recovery. 

CHRONIC PERICARDITIS WITH ADHESIONS 

This condition is commonly caused by rheumatism or tuberculosis. In 
rare instances there is no history of an acute attack, the disease being in- 



514 PERICARDITIS 

sidious in its onset. Nearly all cases follow acute pericarditis; in the 
great majority pericardial adhesions are left, which permanently cripple 
the heart. The pericardium is thickened and its visceral and parietal 
layers are adherent, completely or partially obliterating the pericardial 
sac. Adhesions may also bind it to the diaphragm, pleura, or chest wall. 
A low grade of chronic myocarditis usually follows, resulting in increasing 
dilatation and increasing weakness of the cardiac muscle, and finally re- 
sulting in death from cardiac insufficiency. In other instances, especially 
in those cases of rheumatic origin, the cardiac muscle, forced to do ex- 
traordinary work, because of pericardial adhesions, becomes greatly hyper- 
trophied. These cases may live for many years under proper medical 
supervision. 

Symptomatology. — The symptoms, as a rule, are those of gradually in- 
creasing myocardial insufficiency; the pulse is rapid, weak, and irregular, 
easily influenced by slight exertion. Cardiac pain and dyspnea are usually 
developed by exercise; sudden death from cardiac insufficiency may occur 
at any time. In other instances there is slow failure of the cardiac muscle, 
lasting over months or years. 

The most characteristic physical sign is a retraction of the chest wall, 
especially noticeable over the lower cardiac area, occurring with every 
systole. Immobility of the heart is a valuable sign; the position of the 
apex does not move with a change in the position of the child. There is 
an exaggerated diastolic shock accompanying the second sound over the 
greater part of the pericardium (Broadbent). Friction sounds may be 
heard, but, as a rule, are not present. The area of cardiac dullness is 
greatly increased and X-ray pictures show great increase in the size of the 
heart, and may show adhesions. The valve sounds, which may be present 
in these cases, may be due to chronic endocarditis or to dilatation, with a 
resulting valvular insufficiency; when present they confuse rather than 
assist in the diagnosis of adherent pericardium. Pericarditic pseudo- 
cirrhosis of the liver may occur (Pick's disease). 

Diagnosis. — The diagnosis is very difficult if the characteristic sign of 
systolic chest retraction is not present; the diagnosis, however, may oft- 
times be inferred if the physician was fortunate enough to have seen and 
made the diagnosis of the acute pericarditis, which was afterward followed 
by the symptoms of myocardial insufficiency above noted. 

Treatment. — The treatment, of this condition is the same as that of the 
myocardial insufficiency, which occurs in chronic valvular lesions. 



SECTION IX 
DISEASES OF THE BLOOD AND DUCTLESS GLANDS 

CHAPTER LX 
THE BLOOD 

Red Blood Corpuscles (Erythrocytes). — Normal adult blood contains 
5,000,000 red blood corpuscles, 7,500 white blood corpuscles, and 200,000 
blood plates to the cubic millimeter. Erythrocytes (red blood corpuscles) 
are the hemoglobin carriers, and the potency of their most important func- 
tion, that of bearing oxygen from the lungs to the tissues, depends upon 
the amount of hemoglobin they contain. Hemoglobin is therefore the 
most important constituent of the blood. The specific gravity of the blood 
varies directly with the amount of hemoglobin it contains. The normal 
erythrocyte (normocyte) has no nucleus and varies in size from 6 to 
9 jjl. Larger and smaller forms are frequently met with. The small red 
blood corpuscles are known as micro cytes; they may be less than half the 
size of the normocyte, varying from 5 to 3 pi. The large red blood cor- 
puscles are called macrocytes (9 to 12 fi), megalocytes (12 to 16 /*), and 
gigantocytes (16 to 20 yu). All the above forms of red blood corpuscles are 
non-nucleated and may appear normally in the blood of very young infants. 
The very large and very small forms are pathological, except during the 
early days of life. They may be present in considerable numbers in all 
forms of anemia, but they have not the pathological significance of the 
nucleated forms (erythroblasts) . The following varieties of ery- 
throblasts occur: Normoblasts are nucleated red blood corpuscles of nor- 
mal size. They are the immediate antecedents of normal red corpuscles, 
and occur normally in the blood of the embryo in large numbers; a few 
may be found during the first few days after birth, but soon disappear. 
Each normoblast contains a round, sometimes irregular, darkly staining 
nucleus, one-half the diameter of the cell. They are found in all forms 
of severe anemia, both primary and secondary. Megaloblasts (glganto- 
blasts) are red blood cells two or three times the normal size, containing 
a large, round, or irregularly shaped nucleus. The cytoplasm is frequently 
polychromatophilie, and those cells of irregular shape are called poil'ilo- 
blasts; the presence of these corpuscles, especially in large numbers, indi- 

515 



516 THE BLOOD 

cates a severe type of anemia. Microolasts are red blood corpuscles often 
less than half the normal size, containing a small, deeply staining nucleus. 
They are seen in primary and in severe types of secondary anemia. 

Poikilocytosis is the term used for the distorted and irregularly shaped 
and sized red blood corpuscles; they occur in various types of anemia, 
especially the grave primary forms. In the more severe types these ill- 
shaped irregular forms are present in great numbers. By anisocytosis is 
meant a variability in size of the red corpuscles in a given specimen. 
Oligocythemia, or a scarcity of red corpuscles, is most marked in per- 
nicious anemia and in the anemias of infancy and early childhood. Poly- 
cythemia, an increased number of red corpuscles per cubic millimeter, 
occurs frequently in the anemias of infancy and early childhood, especially 
of the chlorotic type, and also as a clinical entity in later life. In poly- 
chromasia, or polyehromatophilia, the red cells show a varying affinity for 
basic dyes in addition to their normal reaction to acid dyes; this may occur 
in any form of the primary and secondary anemias, but is not marked in 
chlorosis. Oligochromemia, or a scarcity of hemoglobin per unit volume 
of the blood, is still more characteristic of the anemias of childhood than 
of adult life. The color index of the blood refers to the total amount of 
hemoglobin as related to the number of red cells. It is determined by 
dividing the per cent, of hemoglobin by the per cent, of red blood cells. 
The normal per cent, of hemoglobin in infancy is 58 to 78, and the normal 
per cent, of red blood cells is 100; the color index of the normal infant is 
therefore 70 divided by 100, or 0.70. In anemic conditions in infancy the 
normal low color index is still further reduced; that is to say, the anemia 
tends toward the chlorotic type, in which there is a greater reduction of 
hemoglobin than of red blood corpuscles. 

White Blood Corpuscles, (Leukocytes). — White blood corpuscles are 
represented by the following varieties: Small lymphocytes (small mono- 
nuclear leukocytes) are about the size of a red blood corpuscle, consisting 
of a large nucleus, surrounded by a narrow rim of cytoplasm. They are 
the predominating form in infancy and early childhood. During the 
first year of life they represent from 53 to 55 per cent, of all leukocytes, 
while in the adult they represent only about 24 per cent. There is a grad- 
ual diminution in the percentage of small lymphocytes throughout child- 
hood. They are formed in the spleen, lymph nodes, and other lymphatic 
tissues. The small lymphocytes are notably increased in whooping-cough, 
measles, in severe forms of anemia, in the status lymphaticus, and in all 
conditions in which there is a hyperplasia of the spleen and other lymphatic 
tissues. They are enormously increased in the lymphatic form of leukemia. 
Large lymphocytes are two or more times the size of the small lymphocytes, 
and contain a large oval nucleus surrounded by a narrow rim of cytoplasm. 
The large mononuclear leukocytes (splenocytes) are two or three times the 
size of red corpuscles and contain a large single nucleus in a large amount 
of nongranular or faintly granular cytoplasm. The nucleus is frequently 
irregular, and when it shows a marked indentation the cell is called a 



WHITE BLOOD CORPUSCLES 517 

"transitional cell." These cells represent from 3 to 6 per cent, of the total 
number of leukocytes, although they are frequently much more numerous 
in infancy and early childhood. They are formed chiefly in the spleen. 
Polymorphonuclear neutrophiles are about 12 ft in diameter, a little less 

than twice the size of the red blood corpuscle. They each contain a 
chromatin-rich nucleus which is polymorphous, and may resemble the 
letters E. V. S. Y and Z. or show wreathed or rosette forms. This nucleus 
is surrounded by a neutrophilic granular cytoplasm. In infancy they rep- 
resent 35 per cent, of the total number of leukocytes, and gradually in- 
crease in percentage throughout childhood to from 60 to 70 per cent, in 
the adult. They are produced, as are other granular cells, by the bone mar- 
row, and descend directly from the neutrophilic myelocytes. They are in- 
creased in diphtheria, pneumonia, scarlet fever, smallpox, meningitis (the 
tuberculous form excepted), rheumatism, and especially in all septic cases 
such as septicopyemia, septicemia, appendicitis, peritonitis, septic arthritis 
and acute inflammatory processes of all kinds : they are also found in great 
excess in myelogenous leukemia. Eosinophils are generally slightly larger 
than the neutrophiles above described: the nuclei are usually bi-lobed. fre- 
quently tri-lobed and polymorphous : they differ from the neutrophiles also 
in having large refractive granules, which stain with acid dyes, such as 
eosin. They are formed by the eosinophile myelocytes in the bone marrow. 
In infancy they represent only 1 or 2 per cent., and in adults 1 to 4 per 
cent., of the total number of leukocytes. They are increased by diseases 
due to animal parasites, such as trichiniasis and uncinariasis, in chronic 
skin diseases, leukemia and other diseases of the bone marrow, postfebrile 
conditions, and in bronchial asthma. Basopliiles, or mast cells, are gran- 
ular cells slightly smaller than the neutrophiles. having a somewhat ir- 
regular, frequently knotted or tri-lobed nucleus ; the granules, generallv 
large, stain only with basic dyes. They are very scanty in normal blood. 
and a proportion of 1 per cent, or over is pathological. They are of diag- 
nostic value in myelogenous leukemia, where they are greatly increased. 

Blood platelets are small, probably non-nucleated forms, believed by some 
to be related to the white blood corpuscles, by others to the red corpuscles. 
They are of irregular shape, from "2 to 3 /.i in diameter, and their average 
number is from 200.000 to 300.000 to the cubic millimeter, according to 
various observers. In pathological conditions their number may be less 
than 10.0,000 or more than 300,000. Enrther than that they are concerned 
in the formation of fibrin and in the clotting of blood, their phvsiological 
significance is not known. They are increased in posthemorrhagic and sec- 
ondary anemias, pneumonia and tuberculosis, and especiallv in mvelosenous 
leukemia. They are decreased in lymphatic leukemia, pernicious anemia, 
hemophilia, and in some forms of purpura. 

Pathological White Corpuscles. — Myelocytes (marrow cells') are 
usually larger than the polymorphonuclears, but they may varv in size. 
They contain one large oval nucleus, surrounded by a rim of protoplasm 
containing granules, either neutrophilic or acidophilic. This cell occurs 



518 THE BLOOD 

very rarely in the blood of the new-born, and otherwise is found in the 
peripheral blood only in pathological conditions. It represents the imma- 
ture (polymorphonuclear) leukocyte which has been hurried out from 
the bone marrow before its completion. Three varieties may occur: 
neutrophilic myelocytes, the granules of which stain with neutral dyes; 
eosinophilic myelocytes, the granules staining a brilliant red with eosin; 
basophilic myelocytes, the granules of which stain only with basic dyes. 
Myelocytes may be found in infancy in all conditions in which there is a 
marked leukocytosis. They are always present in large numbers and are 
of special diagnostic importance in myelogenous leukemia, and also in 
disease of the bone marrow and other blood-forming structures. 

Peculiarities of the Blood in Infancy and Childhood. — The blood of 
infants differs materially from that of adults. It is an immature tissue, 
which gradually approaches the adult type. The morphological changes 
which take place in the blood throughout infancy and childhood are clearly 
portrayed in the accompanying tables. In fetal life both red and white 
blood corpuscles are produced by the same blood-forming organs, the liver, 
bone marrow, spleen, thymus and lymphatic tissues in general ; but toward 
the end of embryonic life, the liver, under normal conditions, loses this 
function, but still continues for a time to hold a reserve supply of iron, 
from which hemoglobin is made during the early days of postnatal life. 
After birth the marrow, spleen and lymphatic tissues continue to be the 
important blood-forming organs, and nature then makes the attempt to 
differentiate the special work of these organs, so that the red blood cor- 
puscles and granular leukocytes (polynuclear neutrophiles, mast cells, 
eosinophiles and myelocytes) may have their origin exclusively in the bone 
marrow, and the lymphocytes exclusively in the spleen, lymph glands and 
other lymphatic tissues. This differentiation is almost perfectly established 
in the adult, but in the infant, under certain abnormal conditions, when 
there is a great demand made upon these blood-forming organs for either 
the production of red or white cells, there may be a return to the fetal 
conditions, in which both red and white cells are produced in all of the 
blood-forming organs. In the more severe forms of anemia the liver itself 
becomes enlarged and again assists in the blood-forming process. The 
greatest portion of this extra work falls, however, upon the spleen and 
lymphatic glands. These organs, especially the spleen, become greatly en- 
larged by a true hyperplasia, which occurs in response to the demand for 
this increase of function. This reversion of function is an explanation 
of the fact that in the anemias of infancy and young childhood there is 
a tendency on the part of the blood to revert to the infantile type; that 
is to say, the red blood corpuscles vary greatly in size, shape, and staining 
reaction, and nucleated forms are present. The blood in infancy, being in 
a formative stage, is much more vulnerable, and very great changes may 
be produced in it from comparatively slight causes. The blood-forming 
organs at this period are taxed to their full capacity under normal condi- 
tions, so that when any unusual call is made upon them, as in the severe 



THE BLOOD IN INFANCY AND CHILDHOOD 519 

anemias of childhood, they are unable to meet the increased demands. This 
susceptibility of the blood to injury, and this lack of reserve power in the 
blood-forming organs, are the reasons why infants bear hemorrhage badly, 
and why such pronounced anemias develop from comparatively slight 
causes. 

The marked deficiency of the blood-forming organs of the infant, and 
their lack of reserve power in the production of red blood corpuscles, do 
not hold true for white blood corpuscles. In infancy there is a normal 
leukocytosis, the variations and the special characteristics of which, through- 
out infancy and childhood, are detailed in the following tables. This leuko- 
cytosis is very readily increased by slight causes in the infant, so that little 
pathological significance attaches to a count under 20,000 in a child less 
than four years of age. After the sixth year the leukocyte picture ap- 
proaches closely to the adult type, and counts made after this time of life 
have almost the same interpretation that they have in the adult. In the 
comparative study of the leukocyte blood pictures of the child and adult, 
it is important to remember that up to the sixth year of life the mono- 
nuclear cells or lymphocytes are relatively and actually greatly increased 
in numbers, and, since these cells are produced by the spleen, lymph glands, 
and other lymphatic tissues, their presence in increased numbers indicates 
an excessive activity of lymphatic tissues during this period of life. This 
accounts for the prevalence of lymphatic diseases in infancy and child- 
hood, and also explains why the leukocytosis which occurs in the well- 
marked anemias of childhood as a result of disease or overwork of the 
blood-forming organs is commonly of the lymphocytic type. Digestive 
leukocytosis, however, which is very marked in infancy, and leukocytosis 
produced by general sepsis, are in the child, as in the adult, of the poly- 
morphonuclear type. 

The hemoglobin changes which occur in the blood of the infant and 
which are clearly portrayed in the following tables are of great physiological 
and pathological importance. The high percentage of hemoglobin which 
occurs at birth and which continues for a number of days is the continua- 
tion of the fetal condition, kept up by drawing upon the store of iron 
which the liver contains at this time. There is a sharp fall in hemoglobin 
about the third week of life, which is due partly to the exhaustion of the 
fetal supply of iron and partly to the dilution of the blood, which results 
from the large quantity of fluid taken by the infant. From this time on 
throughout childhood there is a slow increase in the amount of hemoglobin, 
but it does not approach the normal until the tenth year of life. During 
all of this time the child has a normal red cell count, so that each red 
corpuscle must be deficient in hemoglobin. In other words, there is a nor- 
mal chlorotic condition, or low color index, which continues throughout 
early childhood. In all diseases which affect the blood or blood-forming 
organs, producing anemia, the hemoglobin suffers first and the chlorotic 
condition is increased. This is one of the marked characteristics of the 
anemias of childhood. 



520 



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and early childhood cannot be interpreted by adult standards. These 
pictures may closely resemble pernicious anemia and leukemia in the adult 
and yet be due to causes that yield more or less promptly to treatment. 
The above tables will assist materially in the interpretation of blood pic- 
tures at different ages. The following blood changes are more or less 
characteristic of the anemias of infancy and young childhood. First, a 
marked deficiency of hemoglobin without a corresponding decrease in the 
number of red blood corpuscles, indeed frequently with an increased num- 
ber of red corpuscles ; this produces a low color index, or so-called chlorotic 
condition of the blood. Second, great variations in the size, shape and 
staining reaction of red blood corpuscles, and the presence of many 



522 SIMPLE SECOKDABY ANEMIA 

nucleated forms. Third, a leukocytosis, mild or severe, the nongranular 
cells or lymphocytes often predominating. 

Enlargement of the spleen and other lymphatic tissues is very com- 
monly associated with the secondary anemias of infancy. This association 
of splenomegaly and secondary anemia has been very generally utilized in 
the classification of these anemias. 



CHAPTEE LXI 
SIMPLE SECONDAEY ANEMIA 

The simple secondary anemias are so called because they are sec- 
ondary to some clearly defined disease or condition which causes destruc- 
tion of or interferes with the formation of hemoglobin and red blood cor- 
puscles. They are thereby distinguished from the primary and pernicious 
anemias, the causes of which are unknown, whose well-defined blood pic- 
ture is, in the present state of our knowledge, considered to be due to some 
pathological factor which acts on the blood-forming organs. The blood pic- 
tures, however, presented by the secondary anemias of infancy and child- 
hood are not so clearly differentiated from the primary anemias as they 
are in adult life. The embryonic type of blood contains a number of 
varieties of corpuscles which are considered more or less characteristic of 
the primary anemias of adult life, but which do not occur in the secondary 
anemias of the adult; while, on the other hand, in the secondary anemias 
of infancy and young childhood there is a tendency on the part of the cor- 
puscles to revert to the embryonic type. For this reason they may present 
a blood picture containing the various varieties of nucleated red blood cor- 
puscles and also red corpuscles varying greatly in their size, shape, and 
staining qualities, thus presenting a picture which may possibly be con- 
fused with the primary anemias. In addition to this, it is believed that 
the primary or pernicious anemias of early life may sometimes begin as 
simple anemias. 

Etiology. — Simple anemia may be hereditary, the infant being born 
anemic and inheriting from diseased parents weak or defective blood- 
forming organs, which are unable to meet the demands of the rapidly 
growing body. Chronic intestinal toxemia and diseases of the gastro- 
intestinal canal are the most common causes of this condition in infancy. 
Chronic glandular tuberculosis is one of the most common causes of anemia 
in childhood, and where other causes are not apparent this condition is 
to be suspected. Among the other common anemia producers are non- 
tuberculous adenitis, rheumatism, malaria, syphilis, contagious diseases 
such as influenza and diphtheria, malignant disease, status lymphaticus, 
prolonged suppuration, chronic nephritis, intestinal parasites, loss of blood 
from hemorrhage, bad air, lack of sunshine and poor food. These latter 



DIAGNOSIS 523 

causes are potent factors in producing anemia among the poor of our large 
cities. 

Symptomatology. — General Symptoms. — That the child is anemic is 
first made evident by the facts that the skin is pale, transparent or per- 
haps sallow, and that the mucous membranes gradually lose their color. 
The blanching of the skin and mucous membranes will vary with the po- 
tency of the underlying cause. In severe cases, especially in infancy, the 
skin may become edematous. The child lacks energy, is listless, has no 
appetite, and, as a rule, surfers from constipation and digestive disturb- 
ances. There is a gradual failure in health, the child losing in weight and 
strength. It has little endurance, is easily fatigued and surfers from short- 
ness of breath on exercising. Nervous symptoms are always present; the 
child becomes irritable, sleepless, hysterical, frequently suffers from night 
terrors, headache, habit spasms, incontinence of urine, chorea, and other 
neuroses. In a large percentage of these cases the physician's attention 
is directed to the anemia in trying to discover the cause of a recently de- 
veloped nervous syndrome. 

In pronounced cases of anemia the heart is weak, rapid, irregular, and 
may be dilated. Hemic murmurs may frequently be heard over the base 
of the heart, and not uncommonly these murmurs, which are very distinct 
with the child lying upon its back, disappear when the upright position is 
assumed. The peripheral circulation is poor, the child is easily chilled, 
suffers from cold hands and feet. Slight enlargement of the spleen may 
be present without special pathological significance. The liver is also 
frequently increased in size. 

Blood Examination. — From the above symptom group the diagnosis 
of anemia may be easily made, but the character and extent of the anemia 
must be determined by a blood examination. In interpreting the blood 
picture presented, the normal low hemoglobin percentage of infancy and 
early childhood must be kept in mind. There is an increased reduction of 
hemoglobin, and frequently a marked decrease in the number of red blood 
corpuscles, though in some cases the count may be nearly normal. The 
color index is low; that is to say, there is a proportionately greater de- 
crease in hemoglobin than in red blood corpuscles, so that the anemia is 
mildly chlorotic in type. In severe cases the hemoglobin may be reduced 
to 25 or 30 per cent., and the red blood corpuscles may show a count of 
4,000,000 to 5,000,000 or over, but in the very severe cases there is a great 
decrease, sometimes to 1,500,000. Irregularities in the shape and size of 
red blood corpuscles also occur, and nucleated forms are present. These 
are chiefly normoblasts, but in severe forms microblasts and megaloblasts 
may also occur. Leukocytosis frequently is present; this is commonly due 
to an increase in the lymphocytes, especially in gastrointestinal conditions ; 
an increase in polymorphonuclears generally denotes some complication. 
If intestinal parasites be the cause of anemia, eosinophilia is marked. 

Diagnosis. — In the vast majority of cases the diagnosis of secondary 
anemia can be made in the child, as in the adult, by the blood picture 



524 PSEUDOLEUKEMIA OF INFANTS 

alone. It is only in the very severe types where megaloblasts occur and 
polychromasia exists that the diagnosis may be in doubt, but even in these 
conditions the presence of an exciting cause, the great preponderance of 
normoblasts as compared with the megaloblasts, and the low color index 
should be sufficient to exclude pernicious anemia, a very rare disease in 
childhood. 

In those cases associated with enlarged spleen and marked leukocy- 
tosis there may be great difficulty in deciding when the condition ceases 
to be a simple, secondary anemia, and becomes the pseudoleukemia of in- 
fancy (von Jakseh's disease). In this differentiation the blood picture 
of the latter disease will be of assistance. 

Prognosis. — The prognosis, in the vast majority of cases, is good, 
since the secondary anemias of infancy and childhood, as a rule, depend 
upon removable causes. 

Treatment. — Since secondary anemia is a symptom of some other 
disease, or is produced by remedial causes, the object of the physician 
should be to search carefully for the underlying causes and remove them. 
Fresh air, sunshine, good food, proper hygienic surroundings are impor- 
tant whatever may be the causative factor. Arsenic and cod-liver oil are 
valuable adjuncts in the treatment of almost all forms of anemia, and some 
easily assimilated form of iron is especially indicated, as it furnishes the 
material from which the blood-forming organs manufacture hemoglobin. 
Constipation and all abnormal conditions of the gastrointestinal canal 
must be carefully treated, and the child fed at regular intervals on a 
wholesome food suited to its digestive capacity. 



CHAPTER LXII 

PSEUDOLEUKEMIA OF INFANTS 

(Von Jakseh's Disease) 

Under this term von Jaksch in 1889 described a rather clearly defined 
symptom group, characterized by the blood picture of grave secondary 
anemia, with leukocytosis, enlargement of the liver, spleen, and sometimes 
other lymphoid tissues. He believed this condition to be a distinct clinical 
entity, but the trend of opinion at the present time is that the cases 
grouped under this term are severe secondary anemias associated with 
enlarged spleen, occurring almost exclusively in infancy, and that age is 
largely the determining factor in the production of this type of anemia* 
The enlarged spleen, which is one of its distinguishing characteristics, 
is but one of the manifestations of the underlying pathological process, 
which is probably toxic in character. It is not to be considered as a causa- 
tive factor. 

Etiology. — Age is the all-important predisposing factor. The great 



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DIFFEEEXTIAL DIAGNOSIS 525 

majority of these cases occur during the last half of the first year of life, 
but this disease may occur as late as the third or fourth year. The imma- 
turity of the blood of the infant makes it especially vulnerable to toxic 
and other injurious influences, so that the normal blood picture at this 
age is easily disturbed by causes which later in life would have little effect 
upon the mature blood. 

Chronic gastrointestinal intoxication associated with artificial feeding 
is the most important exciting factor. Unhygienic surroundings, diarrhea, 
constipation, chronic indigestion, syphilis, rickets, and secondary anemias 
are the usual antecedents of this condition. It is rare in breast-fed babies. 

Symptomatology. — Blood Picture. — The hemoglobin and red blood 
corpuscles are markedly diminished, the former to 20 or 30 per cent., the 
latter to 2,000,000 or 3,000,000 to the c. mm. ; in rare cases to under 1,000,- 
000. The red corpuscles vary greatly in shape (poikilocytosis) ; small red 
cells (microcj'tes) and large red cells (megalocytes) are present, nucleated 
forms (normoblasts and megaloblasts) may be found, and polychromato- 
philia may occur. The white blood cells are increased, a leukocytosis of 
from 30,000 to 50,000 being common. Mononuclears and polymorphonu- 
clears predominate, eosinophils are commonly present, and neutrophilic 
and eosinophilic myelocytes may be found. 

Other Symptoms. — Pallor of the skin and mucous membranes is very 
marked. The spleen is enlarged, hard, not tender to the touch. It may 
extend as low as the crest of the ilium, or may be felt but slightly below 
the edge of the ribs. Its size is not always in proportion to the severity 
of the other symptoms of this disease, yet it is the most distinguishing 
feature of the clinical picture. The liver is commonly slightly enlarged, 
and the superficial lymph nodes easily palpable. Slight hemorrhages into 
the skin and mucous membranes are common. An irregular fever may 
occur. 

Obscure digestive disturbances should be carefully searched for. Con- 
stipated stools, mucous discharges, intestinal fermentation and indigestion 
are common, and indican is usually found in excess in the urine. The 
appetite is lost, the patient is listless and grows progressively weaker and 
more emaciated. 

Differential Diagnosis. — From leukemia, the disease with which this 
condition is most commonly confused, it can only be differentiated by re- 
peated blood examinations. The blood count in this condition shows few 
myelocytes and a moderate leukocytosis, while in leukemia the myelocytes 
are present in large numbers and the leukocytes enormously increased. 
In von Jaksch's disease the number of leukocytes seldom exceeds 50,000, 
and there is practically a sustained percentage of the various varieties of 
leukocytes in spite of the presence of the myelocytes. A large number of 
nucleated red corpuscles are commonly seen. In leukemia the liver and 
lymph nodes are much more enlarged. 

From secondary anemias due to rickets, syphilis and other causes the 
diagnosis is made largely by the severity of the whole clinical syndrome. 



526 CHLOEOSIS 

The spleen is much larger, the leukocytosis more marked, and megalo- 
blasts and myelocytes are more commonly seen. 

Pernicious anemia rarely, if ever, occurs in infancy, and is not to be 
considered, therefore, in the differential diagnosis, although the blood 
picture of this condition may very closely resemble that of pernicious 
anemia in the adult. 

Prognosis.- — The majority of these cases recover under careful treat- 
ment. The condition, however, is always to be considered a grave one, and 
the prognosis should be carefully guarded until definite signs of im- 
provement begin. 

Treatment.- — The indications for treatment are as follows: 

First. — Eemove the intestinal intoxication, which is commonly present. 
This comprehends the careful treatment of any abnormal gastrointestinal 
condition. If constipation be present, mild laxatives, such as milk of 
magnesia, may be used from day to day, with a dose of castor oil at in- 
tervals of four or five days. For a child one year of age, one grain of 
either salol, betanaphthol, or carbonate of guaiacol should be given every 
three hours as an intestinal antiseptic throughout the treatment. Great 
stress should be laid on the antiseptic treatment of these cases, even though 
gastrointestinal disturbances be not clearly evident. 

Second. — Improve the infant's nutrition by selecting a diet within 
the range of its digestive capacity, and at the same time of such a character 
that it will serve nutritional purposes. Breast-milk is the best of all foods 
for this purpose, and many of these cases will rapidly improve if a suitable 
wet-nurse is secured. If wet-nursing be impracticable, these infants should 
be fed along the lines outlined in the chapter on Chronic Intestinal In- 
digestion. Peptonized milk is a valuable food in these cases. 

Third. — Improve the blood state and general tone of the infant by 
keeping it out of doors as much as possible. Fresh air is very important, 
and if the weather conditions will not permit the fresh-air treatment at 
home, a change of climate may be recommended. 

Fourth. — Treat the anemic condition directly by giving some form of 
organic iron, preferably combined with one of the malt preparations. The 
use of iron, however, in this condition must not be persisted in if the 
gastrointestinal canal is disturbed by it. In such cases the subcutaneous 
use of neutral citrate of iron in %-grain doses is of value (Friedlander). 
Arsenic is of no value in this disease. 



CHAPTEE LXIII 

CHLOROSIS 

Chlorosis is a secondary anemia characterized by deficient hemogenesis, 
producing a marked decrease in hemoglobin without a corresponding re- 
duction in red blood corpuscles. This results in a low color index and a 
more or less characteristic greenish-yellow color of the skin. 



TREATMENT 527 

Etiology. — It occurs almost exclusively in young girls about the age 
of puberty, and for this reason it may be inferred that nervous influences 
incident to the development of the sexual organs have something to do with 
its production. It is frequently seen in brunettes. It is extremely rare in 
boys. The most important predisposing factors are believed to be improper 
food, a deficiency of food, fresh air and sunlight. It occurs most commonly 
among factory and shop girls who spend long hours under unfavorable 
hygienic conditions. Constipation and intestinal intoxication, as Andrew 
Clark believed, are perhaps important factors. True chlorosis probably 
does not occur in infancy and young childhood, although the blood pic- 
ture presented by secondary anemia at this age is, as already noted, of the 
chlorotic type. 

Symptomatology. — The general symptoms are very like those of well- 
marked secondary anemia. The skin in advanced cases of chlorosis, how- 
ever, has a yellowish-green pallor unlike that of secondary anemia, and the 
neurotic disorders which are so marked a feature of the secondary anemias, 
are not so pronounced in chlorosis, although the patient may be nervous, 
irritable and even hysterical, but chlorosis occurs later in life, and for 
this reason the nervous system, which is better developed, is not so pro- 
foundly affected. Cases of chlorosis do not surfer such marked nutritional 
disturbances as are present in well-marked secondary anemias. Shortness 
of breath, rapid and irregular heart action, cardiac dilatation, hemic mur- 
murs, epigastric pain, gastrointestinal disturbances, headache, acne and 
irregular fever may occur. Constipation is a common and an important 
symptom. In older girls dysmenorrhea or amenorrhea may be present. 

The blood picture is very characteristic, and by it the diagnosis is 
made. The hemoglobin is greatly reduced; it may be as low as 20 or 30 
per cent., while the red blood corpuscles may be but slightly diminished in 
number. In severe cases, however, they are also much reduced, but not in 
a corresponding degree with the hemoglobin, so that the color index of 
the blood may be so low that the color of the red corpuscles is but faintly 
discernible. These almost colorless corpuscles vary in size and shape. 
Normoblasts appear in small numbers in severe cases, and are not an un- 
favorable sign, since they indicate blood regeneration. Microcytes may 
be present, and megaloblasts are extremely rare. The leukocytes are nor- 
mal in number, but there may be a relative lymphocytosis. 

Diagnosis. — The above blood picture occurring in girls between the 
ages of twelve and eighteen easily suffices to make a diagnosis. 

Prognosis. — In uncomplicated cases the disease yields readily to treat- 
ment. 

Treatment. — Fresh air, sunshine, and good food greatly facilitate the 
cure. A carefully selected diet of nutritious food, within the range of the 
digestive capacity of the patient, is important. The gastrointestinal canal 
must be kept in good condition, and it is very necessary that constipation 
be overcome with non-irritating laxatives. The proper use of iron is by 
far the most important therapeutic measure in the treatment. Under 
35 



528 PEKNICIOUS ANEMIA 

its use the anemia gradually disappears, and the blood returns to its nor- 
mal condition. Iron is perhaps best given in the form of Blaud's pills, 
5 to 10 grains after meals, until the blood condition is materially improved; 
the dose may then be diminished to three or four pills a day. This treat- 
ment is to be continued for six weeks, or longer, if necessary. Saccharated 
carbonate of iron, reduced iron, and organic iron, in combination with 
malt preparations, may be used if gastrointestinal conditions demand them. 
Two or three grains of reduced iron, one or two grains of quinin and one- 
thirtieth of a grain of arsenic may be advantageously combined in the 
same capsule. Forchheimer recommends that five grains of betanaphthol 
or salol be given before meals, in connection with the iron therapy. 

Patients recovering from chlorosis should not be allowed to return to 
the same unhygienic surroundings under which they developed the disease ; 
otherwise relapses may occur. 



CHAPTEE LXIV 

PEKNICIOTJS ANEMIA 

This is a very grave form of anemia. It is characterized by a well- 
defined blood picture and by severe constitutional symptoms, which, al- 
though subject to strange remissions in severity, gradually grow worse 
until in the great majority of cases death results. It is an extremely rare 
disease in childhood, but when it does occur it presents the same clinical 
picture as in the adult. 

Etiology.- — The fish tapeworm, the hookworm and the malarial parasite 
may produce a form of pernicious anemia in which the blood picture 
is identical with the ordinary form of this disease, whose etiology is not 
understood. In childhood it is believed to be associated with syphilis, 
rickets, and chronic intestinal disorders, and rarely to be developed from 
severe forms of secondary anemia. 

Symptomatology.— General Symptoms. — The symptoms are the same 
as in the adult. There is marked and progressive pallor of the skin, asso- 
ciated with muscular weakness, dyspnea, and heart symptoms similar to 
those found in severe secondary anemias. Vertigo, tinnitus, edema, gas- 
trointestinal disorders, associated with pain, more or less marked disturb- 
ance of the functions of the spinal cord, and hemorrhages into the skin 
and from the mucous membranes very frequently occur. The diagnosis, 
however, of the disease is made from the blood picture. 

Blood Picture. — There is a marked reduction in the number of red 
blood corpuscles, in advanced, cases as low as 1,000,000 per c. mm., and 
even less. The hemoglobin is also reduced, but, as a rule, not to so great 
an extent as the corpuscles, so that each red cell contains an excess 
of hemoglobin. This produces a high color index, and is one of the most 
characteristic of the blood findings, especially in children, since the color 



TREATMENT 529 

index with them in all other forms of anemia is comparatively low. Ex- 
treme poikilocytosis and basophilia are commonly present, and the size of 
the red blood corpuscles is in the average increased; megalocytes are com- 
mon; this is an important diagnostic sign. Polychromatophilia frequently 
occurs. Normoblasts and megaloblasts are seen, the former in larger 
numbers. The red cells lose their rouleaux formation. The leukocytes 
are normal or subnormal in number, but the polynuclear cells are relatively 
diminished and myelocytes may be present. 

Remissions. — This is a disease in which strange remissions may ap- 
pear in the general symptoms and in the blood picture. During one of 
these remissions the patient improves over a period of some months, and 
upon this change false hopes are not infrequently founded. Suddenly, 
without apparent cause, there is an exacerbation in all of the symptoms, 
and the disease progresses steadily downward. 

Diagnosis. — When a case presents the symptoms and blood picture of 
pernicious anemia, the stools must be carefully examined for evidences of 
the fish tapeworm and the hookworm, and the blood examined for the 
malarial parasite. These etiological factors excluded, the diagnosis of the 
ordinary form of pernicious anemia is made. In children, however, as 
previously noted, the blood picture in severe secondary anemias may 
closely resemble that of pernicious anemia, but the rarity of pernicious 
anemia in childhood and the comparatively low color index in secondary 
anemias, when taken in connection with the blood pictures of the two 
conditions, should make the diagnosis clear. If doubt remains for a time, 
the different course of the two conditions will clear the diagnosis. Eosino- 
philia in connection with the typical blood picture of pernicious anemia 
suggests intestinal parasites as the cause. 

Treatment. — The treatment is the same as in the adult, and is unsatis- 
factory. It is questionable whether drugs of any kind influence the course 
of this disease. Arsenic, however, has been for a long time and is still 
in favor. It is to be given in gradually increasing doses until the physio- 
logical effects of the drug are produced, and then diminished to a moder- 
ate-sized tonic dose suitable to the age of the child. Careful attention to 
the gastrointestinal canal, looking to the avoidance of intestinal intoxica- 
tion, is, perhaps, the most important therapeutic measure. Salol and 
betanaphthol should be given over a long period of time. A wholesome 
outdoor life is important. 

In those cases due to the fish tapeworm, the hookworm or the malarial 
parasite, treatment should, of course, be directed toward the removal of 
these causative factors. 



530 LEUKEMIA 

CHAPTEK LXV 

LEUKEMIA 

Leukemia is a blood disease manifesting itself by a great increase in 
the leukocytes and by pathological changes in the bone marrow, spleen, 
liver and lymph nodes. It is very uncommon in infancy and childhood, 
but does occur. 

Etiology. — The etiology of this condition is not at all clear, but in 
childhood it is believed to be etiologically related to syphilis, rickets, 
chronic gastrointestinal conditions, malaria, and severe secondary anemias. 

Symptomatology. — The symptoms of this disease in childhood, as in 
adult life, appear in two rather well-marked clinical types, which are 
largely distinguished by the blood picture presented. The myeloid type 
is much the most common in the adult, and the lymphoid type comprises 
the majority of the cases in infancy and early childhood. In children 
these two types are very commonly mixed, the blood picture being a com- 
bination of the two. In the adult the types are more clearly defined. 

Blood Picture. — In both types, hemoglobin and red blood corpuscles 
are diminished and nucleated forms are seen, but these changes are un- 
important from the standpoint of diagnosis. It is the leukocyte blood 
picture which not only differentiates the two types, but distinguishes this 
disease from all others. 

In the myeloid form we have an enormous increase in leukocytes; 
100,000 to 500,000 are commonly found. A large number of myelocytes 
of different sizes are present; this is the most characteristic feature of 
the blood picture. The large mononuclears and the polynuclear and 
mononuclear eosinophiles are increased. The polynuclear neutrophiles and 
mast cells are also increased, but not to the same extent as the other 
cells mentioned. The special feature of this blood picture is an enor- 
mous leukocytosis with a great increase in myelocytes, polynuclear eosino- 
philes and mast cells. 

In the lymphoid form the lymphocytes are greatly increased in num- 
ber, even as high as 95 per cent, of the leukoc}^tes present ; myelocytes and 
mast cells may be present. There is a diminution in the amount of 
hemoglobin and red blood corpuscles, and some nucleated forms may be 
seen. 

General Symptoms. — The onset and course of the disease are much 
more rapid in young children than in the adult. It commonly progresses 
to a fatal termination within a few months. The whole course of the 
disease may be embraced within a single month. The pallor of the skin 
and mucous membranes is very pronounced; gastrointestinal disturbances 
are common; vomiting is a frequent symptom; hemorrhages may occur 
from the nose and other mucous membranes; blood may be present in the 



PURPURA 531 

stools, and subcutaneous hemorrhages producing dark blue spots may oc- 
cur from slight blows upon the skin. The appetite is lost, the child is 
nervous, irritable, and rapidly and progressively fails in strength. The 
spleen is always enlarged and may be enormously so, extending even to 
the crest of the ilium. The liver dullness is frequently greatly increased 
and the lymph nodes and other lymphoid structures, including the tonsils 
and adenoids, are also notably increased in size. As the disease progresses 
the child's strength rapidly fails, there is shortness of breath, the heart is 
weak, and rapid and repeated hemorrhages may greatly aggravate the 
prostration. The temperature may be normal, or may range from time 
to time as high as 102° or 103 °F. Death occurs from exhaustion. 

Prognosis. ■ — It is questionable whether any of these cases occurring 
in infancy and young childhood ever recover. 

Treatment. — The treatment is unsatisfactory, purely symptomatic, and 
directed toward the relief of suffering; any therapeutic measures to this 
end are justifiable. The X-ray treatment of these cases, after a thor- 
ough trial, has been found to be without therapeutic value. 



CHAPTER LXYI 

PUEPUEA 

Purpura is the name applied to a condition in which there is a transi- 
tory and nonhereditary hemorrhagic diathesis, caused by toxins and other 
contributing etiological factors. It is characterized by a skin eruption 
produced by small spontaneous hemorrhages occurring in the subcutaneous 
tissues. The hemorrhagic spots thus produced are bluish, but gradually 
fade to a brown and then yellow color. This yellow pigment is slowly 
absorbed, removing all discoloration, so that the skin may present a normal 
color within a week or ten days after the initial lesion. New crops of 
purpuric spots occurring from time to time may prolong the eruption 
for an indefinite period. These purpuric spots do not disappear upon 
pressure. The eruption may appear as fine petechial hemorrhagic points, 
but, as a rule, the spots are larger, approaching in size a split pea, and 
sometimes large, irregular hemorrhagic patches occur, resembling an ordi- 
nary bruise of the skin. It may occur on any part of the body, but it is 
most common, and usually first appears, on . the legs, especially over the 
shin bones. The frequent association of purpura with urticaria, erythema 
exudativum, and localized edema, in the various symptom groups classi- 
fied as "purpuras/' indicates that the same toxins may produce these 
various skin lesions by their action through the nervous mechanism that 
controls blood and lymph vessels. This association of symptoms in part 
helps to establish the more or less clearly defined symptom groups below 
referred to. The purpuric eruption very commonly occurs as a symptom 
of constitutional disorders, toxic, cachectic and nervous in their character. 



532 PUBPUEA 

These symptomatic purpuras are not separate clinical syndromes, the rash 
being but one of a large group of symptoms which belong to some well- 
defined constitutional disorder. In other instances the purpura occurs 
as the all-important clinical feature of a distinct syndrome, whose etiology 
is more or less obscure. These cases are spoken of as idiopathic, to dis- 
tinguish them from the clearly defined secondary purpuras. It may be 
that the various forms of purpura are merely clinical syndromes repre- 
senting different phases and different degrees of the same hemorrhagic 
diathesis, but they are here described as distinct disease pictures in order 
that the clinical course of the various symptom groups of this condition 
may be more clearly understood. 

The symptom-complex of the following idiopathic purpuras will be 
here briefly described: Purpura simplex, purpura fulminans, purpura 
hemorrhagica, Henoch's purpura, and purpura rheumatica. 

Etiology. — It is believed that nearly all of the worst forms of purpura 
are due to toxic substances circulating in the blood, and that they act not 
only upon the nervous system, producing profound vasomotor disturb- 
ances, but also directly on the endothelial lining of the smaller blood ves- 
sels, producing degenerative changes. It is known that blood coagulation 
is impaired, that the blood platelets are diminished and that the blood clot 
formed from purpuric blood does not contract firmly. It is believed, es- 
pecially by French writers, that functional disturbances of the liver are 
etiologically related to this condition. 

Symptomatic Purpura. — Symptomatic purpura occurs not uncommonly 
in association with nervous disorders, but this form is rare in children. It 
may also rarely result from the administration of drugs, such as iodid of 
potash, mercury, belladonna, antipyrin, quinin, salicylic acid, chloral, 
ergot, and potassium chlorate. A very pronounced form of purpura can 
be quickly produced by snake venom. The most common cause of sec- 
ondary purpura in infancy and childhood are the acute infections. It may 
occur as part of the symptom-complex in smallpox, diphtheria, scarlet 
fever, measles, cerebrospinal meningitis, septicemia and septic endocarditis, 
and when it does occur in these conditions it adds great gravity to the 
prognosis. In infancy, secondary purpura may occur in hereditary syph- 
ilis, rickets, tuberculosis, chronic ileocolitis, the severe secondary anemias, 
leukemia, and in all conditions producing a profound malnutrition. 

Purpura Simplex. — This condition is characterized by a purpuric erup- 
tion usually symmetrical in its distribution. It first appears on the legs 
and may be confined to the lower extremities, but it usually appears in 
other parts of the body. The rash, commonly petechial in character, ap- 
pears suddenly without constitutional symptoms. There is little or no 
fever. Nausea, vomiting and digestive disturbances may or may not be 
present. The disease runs its course, as a rule, to a favorable termina- 
tion within from two to four weeks. The prolongation of this condition 
is due to the fact that the eruption comes out in successive crops. 

Purpura Fulminans. — This is a rare and very severe form, commonly 



PURPURA HEMORRHAGICA 533 

terminating fatally within one or two days; death may occur within the 
first twelve hours, or may be postponed for four or five days. In a case 
which I reported some years ago death occurred within twenty-four hours. 
This case was a helpless, idiotic, epileptic child, nine years of age, living 
under very unfavorable hygienic surroundings, and in the same room with 
two cases of malignant diphtheria, one of which died on the same day as 
this patient. There was no fever and no hemorrhage from mucous mem- 
branes; the onset of the disease was marked by irritability, refusal to take 
food, and the appearance of a great number of dark blue hemorrhagic 
spots over the legs, scrotum, and abdomen, these spots rapidly increasing 
in size until they ran together, producing a dark blue discoloration over 
the parts above named. Small hemorrhagic spots appeared also over other 
portions of the body, profound prostration was quickly followed by delirium, 
stupor, coma, and death. This is a typical clinical picture of this symp- 
tom group. Convulsions, vomiting and high fever may be present in these 
cases, and albumin is usually found in the urine. In the case above de- 
tailed the inference is that the disease was produced by the toxins of 
diphtheria, although no evidence of diphtheria appeared in the throat. 
Many of these cases are believed to be foudroyant cases of smallpox, 
measles, scarlet fever and other infections. The patients, however, as a 
rule, do not live long enough to develop the characteristic symptoms of 
these diseases. 

Purpura Hemorrhagica. — Purpura hemorrhagica is characterized by 
hemorrhages from mucous membranes, and is thereby distinguished from 
other forms of purpura. These hemorrhages, which are the characteristic 
feature of the disease, occur apparently without exciting cause. Their most 
common site is the nose ; bleeding may also occur from the mouth, especially 
the gums, from the kidneys, the intestinal canal, and, in fact, from any 
mucous membrane. In a case which I reported, the bleeding from the 
nose persisted almost continuously for six days, and bled at intervals 
during the next three or four days, until on the tenth day of the disease 
a blood examination showed 21 per cent, of hemoglobin and 1,300,000 red 
blood corpuscles. The resulting anemia which occurs in some of these 
cases is very great, and in those cases that recover, the increase in the num- 
ber of corpuscles is so much more rapid than the increase in hemoglobin, 
that the anemia assumes for a time a chlorotic type. This is illustrated 
in the chart taken from the report of the case above referred to. 

The purpuric rash in this condition is widely distributed over the body, 
beginning, as a rule, on the legs; the hemorrhagic spots vary in size from 
a pinhead to a silver dollar. In the case above referred to, the baby sister 
of the patient struck him a slight blow on the forehead with an Easter 
egg, producing a dark blue, irregular hemorrhagic spot. The spots, how- 
ever, as a rule, appear spontaneously and may occur in crops from time 
to time throughout the course of the disease. Fever, nausea, vomiting 
and gastrointestinal disturbance may or may not be present. The tempera- 
ture, in the early stages, ranges in the neighborhood of 102 °F. Albumin 



534 



PUEPUEA 



may be found in the urine, and acute nephritis is the most common serious 
complication. Arthritis may occur, but is not, as a rule, a feature of this 
disease. Edema may also be present, but erythema and urticaria, so com- 
monly present in other forms of purpura, are rarely seen in this condition. 
The disease is a serious one, lasting from two to eight weeks, but most 
of the cases recover. In rare instances the disease may resemble typhoid 
fever, having a continuous fever, intestinal hemorrhages, great prostration, 
delirium, and, in fatal cases, coma. These cases, however, should be easily 
differentiated from typhoid by the absence of the Widal reaction, and by 
a careful study of the two symptom groups. 



4,000,000 corpuscles and 80 per cent, hemoglobin 



3,500,000 




" 70 


3,000,000 


.1 


" 60 


2,500,000 


•< 


" 50 


2,000,000 


•• 


" 40 


1,500,000 


•• 


« 30 


1,000,000 


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•' 20 





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Solid* line = number of corpuscles. Broken line = percentage hemoglobin. 
Fig. 82. Diagram Showing Blood Changes in a Case op Purpura Hemorrhagica. 

Henoch's Purpura. — This form, first described by Henoch, occurs most 
commonly in children. The purpura is associated with attacks of severe 
abdominal pain and polyarthritis. The onset may be marked by headache, 
fever, prostration, and the outbreak of a purpuric rash. In some cases, 
however, the arthritis or intestinal colic may precede the eruption, which 
is frequently accompanied by urticaria, erythema, and angioneurotic 
edema. Osier has called attention to the fact that in this form of pur- 
pura, as in others associated with erythema, there may be great variations 
in the appearance of the skin; the purpura, erythema, urticaria and 
localized edema may all be present in an individual case, or again various 
combinations of these skin lesions may occur, and any one may be absent. 
Eecurring attacks of severe abdominal pain is the characteristic symptom. 
It may be associated with violent and prolonged vomiting, and early 
constipation is followed by diarrhea; the stools may contain blood. The 
pain is usually referred to the umbilicus, and is associated with abdominal 
resistance and with tenderness over the upper portion of the abdomen. 
Arthritis occurs in practically all of the severe cases. There may be pain 
and swelling in one or more joints, and successive joints may be involved. 

The acute symptoms of an attack last from a few days to a week; 
within this time the eruption fades, the pain and tenderness of the joints 
disappear, the gastrointestinal disturbances cease, and the patient is ap- 
parently convalescent. Within a week, however, the whole symptom group 
above detailed may recur, and repeated attacks of this character with inter- 
vening periods of apparent convalescence may prolong the illness for 
months, but true convalescence is established in the majority of cases 



TREATMENT 535 

within a month or six weeks. In a few instances the disease becomes 
chronic and lasts over a period of years. Acute nephritis is a dangerous, 
and by far the most common, complication; cerebral hemorrhage, endo- 
carditis and pericarditis may occur. 

The prognosis, on the whole, is good, especially in children. About 
ten per cent, of these cases die from various complications. 

Purpura Rheumatica (Sclionleins Disease). — This is seen in older chil- 
dren, but more commonly in young adults, and is not in any way etiolog- 
ically related to rheumatism, although it may begin with pharyngitis and 
tonsillitis. The purpuric rash resembles that seen in simple purpura. It 
consists largely of petechias associated with slightly larger ecchymotic 
spots, distributed chiefly over the lower extremities, but other parts of 
the body may be involved. In some cases the eruption is more marked 
over the swollen joints and spreads from joint to joint with the arthritis. 

The chief characteristic is the multiple arthritis, and all cases of ar- 
thritis associated with simple purpura, uncomplicated by abdominal colic 
and by hemorrhage from mucous membranes, are classed under this syn- 
drome. The arthritis usually affects the knees and ankles in these cases 
and commonly disappears within a week. 

When the arthritis is the initial lesion and is associated with fever, 
as it is in many of the cases, a diagnosis of rheumatism is ordinarily 
made. The character of the trouble, however, is soon made clear by the 
appearance within a few days of the purpuric eruption and possibly the 
subsequent association of erythema, urticaria and localized edema with 
the purpuric rash. The erythema, urticaria, edema of the hands and feet 
and even typical angioneurotic edema, which is associated with the pur- 
pura in many of the cases of purpura rheumatica, present a clinical pic- 
ture which may closely resemble Henoch's purpura, with the exception of 
the gastrointestinal symptoms of that disease. Albuminuria may occur, but 
nephritis and other complications seen in Henoch's purpura are very rare. 

These cases run a benign course and are commonly convalescent with- 
in a month; relapses, however, are not uncommon. 

Treatment. — The treatment of symptomatic purpura calls, in the first 
place, for the treatment of the underlying causative condition, and, in 
the second place, for the routine treatment of purpura as here outlined, if 
the treatment recommended is not contraindicated by the primary disease. 

General Treatment. — General treatment applicable to all forms of 
purpura. Absolute rest in bed until all symptoms are under control is 
of great importance. The patient should be kept quiet, and should be 
in the hands of competent nurses who can protect him from all possible 
injuries to the skin and mucous membranes. Eresh air, day and night, is 
essential. When the weather will permit and the surroundings are fa- 
vorable, the bed of the patient should be placed out of doors for as much 
of the twenty-four hours as is practicable. 

Diet. — Milk and cereals should be the basis of the diet, and orange 
juice and other fruit juices should be given. Since purpura is a toxic 



536 PURPURA 

condition, and since the kidneys very commonly give way under the irri- 
tation of excreting these toxins, it is most important that these patients 
should be dieted as they are in scarlet fever with the idea not only of 
eliminating toxins, but of protecting the kidneys and other excretory or- 
gans. Rich, albuminous foods, and strong beef broths, should, therefore, 
be avoided in the treatment of all forms of purpura during the acute stage 
of the disease. In addition to the diet above recommended, water should 
be given freely to assist in the elimination of toxins and in the flushing out 
of the excretory organs. During convalescence the diet may be increased 
and fruits, vegetables and albuminous foods may be given. 

Cathartics serve a useful purpose and are indicated in all forms 
of purpura not complicated by intestinal hemorrhage. Calomel, Rochelle 
salts, sulphate of soda, sulphate of magnesia and phosphate of soda not 
only remove offensive matter from the intestinal canal and eliminate tox- 
ins through the intestinal wall, but they also unload the portal circula- 
tion and perhaps favorably influence the functional inactivity of the liver 
which is believed to be present in most cases of purpura. 

Hydrotherapy. — Elimination of toxins should also be promoted 
through the skin. This may be accomplished by the giving of one or two 
warm alkaline baths each day; common salt, sea salt or bicarbonate of 
soda may be used in these baths, and great care must be taken in handling 
the patient, that fresh ecchymoses may not be produced by bruising the skin. 

Medical Treatment. — Calcium lactate is believed to exert a favor- 
able influence by increasing the coagulability of the blood; it may be 
given in five-grain doses to a child six years of age, increasing the dose 
one grain for each year of life until the maximum dose of 15 grains three 
times a day is reached. Fowler's solution has been extensively used and 
is believed to be of value in these cases; it should be given, as in chorea, 
in gradually increasing doses until improvement begins, or until the pa- 
tient is taking 10 drops three times a day. It is perhaps of special value 
in those cases that are believed to be of cachectic or neurotic origin, and 
are associated with marked nervous symptoms. It is contraindicated 
in Henoch's purpura and in all forms where there is gastrointestinal irri- 
tation. 

Iron is a remedy of little or no value during the acute stages of this 
disease, but is a remedy of very great value during convalescence. Its 
special value is in those cases where a more or less marked anemia re- 
sults. The preparation of iron selected will depend largely upon the age 
of the patient and the condition of the gastrointestinal canal. In younger 
children the organic iron preparations and the saccharated carbonate given 
with some form of malt are most valuable. In older patients Blaud's pills 
may be given. 

Treatment of the Special Forms. — The prime object in the treat- 
ment of purpura hemorrhagica is to control as soon as possible the bleed- 
ing from the mucous membrane. Where the bleeding surface can be 
reached, as in the mouth or nose, the parts should be irrigated with a 1 to 



ETIOLOGY 537 

1,000 adrenalin solution, or should be packed with cotton saturated with 
this solution. In hemorrhages from the stomach adrenalin may be taken 
internally in the hope that it may act locally upon the bleeding vessels. 
In the control of hemorrhage the bleeding part should be elevated and 
absolute rest insisted on; the patient should not be allowed to do any- 
thing for himself that can be done by others. If there be hemorrhage from 
the stomach or intestine, the prolonged application of ice to the abdomen 
should be resorted to, and where these measures fail, 5 or 10 minims of 
adrenalin solution may be injected hypodermically. The hemorrhage once 
being controlled, rest in bed and absolute quiet should still be insisted 
upon for a period of a week or ten days, and during this time the general 
treatment of purpura as above outlined should be carried out. During 
convalescence the profound anemia which has resulted from the hemorrhage 
demands the use of iron in large doses. Later the iron may be combined 
with arsenic, and this treatment continued until all traces of the anemia 
have disappeared. 

During the acute stage of Henoch's purpura the gastrointestinal condi- 
tion precludes giving anything except the lightest food, such as cereal 
waters, to which milk may be added. Laxative medication, preferably cas- 
tor oil or sulphate of magnesia, is indicated to relieve the abdominal pain. 
Osier believes that the pain in this condition is due to an edematous con- 
dition of the intestinal wall. This may be the explanation for the relief 
from intestinal pain which the saline cathartics afford in this disease. In 
some instances it may be necessary to give morphin hypodermically. Ice- 
bags to the abdomen may also be of benefit. As the intestinal symptoms 
come under control the bowels are still to be kept open with saline cathartics, 
and milk and cereal gruels are to be continued until all danger from neph- 
ritis is passed. The general treatment is the same as that above outlined. 

The other forms of purpura require no special treatment other than 
that above given. In purpura fulminans all treatment is unavailing. In 
purpura rheumatica the disease runs a benign course and responds to the 
routine treatment of purpura. Salicylates are of no value in this disease. 



CHAPTEE LXVII 

HEMOPHILIA 

Hemophilia is a rare disease, characterized by an hereditary and long- 
continued, if not permanent, predisposition to severe and ofttimes uncon- 
trollable hemorrhages, which may be precipitated by traumas so slight 
as to be undiscoverable. Patients suffering from this disease are popularly 
known as "bleeders." 

Etiology.— Comparatively little is known of the pathology and etiology 
of this condition. It is, however, distinctly hereditary, running through 
families for many generations. In some of the families studied the disease 



538 HEMOPHILIA 

has persisted for two hundred years. The hereditary tendency is, in the 
vast majority of instances, transmitted through females, themselves non- 
bleeders, to the male members of a family, thus skipping a generation. 
Direct transmission from parent to child is very unusual. It has a great 
predilection for males; females are comparatively rarely affected, the pro- 
portion being about as one to twelve. It is not unusual in hemophiliac 
families to find more than half of the males descended from the female 
members of the family suffering from this disease, while none of the 
females and none of the males descended from male members of the 
family have the disease. In rare instances, however, it should be remem- 
bered that the disease may descend through the male line and that the 
females may be affected. 

Age. — In the new-born hemorrhages from this cause are rare, but do 
occur. This disease, however, nearly always begins in early childhood. In 
65 per cent, of the cases the first hemorrhage appears during the first 
or second year of life, and children of hemophiliac families who have 
shown no symptoms before the tenth year of life are comparatively safe. 
In rare instances, however, it may appear in adult life. It is especially 
rare in warm climates. 

Symptomatology. — The characteristic hemorrhage is not, as a rule, vio- 
lent, but it is long-continued and, if controlled, sooner or later commonly 
recurs. The surface from which the blood oozes usually shows no sign of 
trauma. The first hemorrhage is rarely fatal, but the subsequent ones 
usually cause death during childhood; less than 15 per cent, reach ma- 
turity. These uncontrollable hemorrhages may last for weeks, or until 
the child dies from exhaustion. Spontaneous hemorrhages may be pre- 
ceded by restlessness, nervousness, vertigo, circulatory disturbances, and 
other prodromal symptoms. If the patient lives to maturity, the tendency 
to these hemorrhages gradually grows less, so that he may even outgrow 
his hemorrhagic predisposition. Very rarely, dangerous and even fatal 
hemorrhages occur after middle life. 

A family history of hemophilia, which is present in nearly every case, 
is hardly less important in making the diagnosis than the characteristic 
hemorrhages above described, since with this family history the diagnosis 
may be made with the onset of the first hemorrhage, and without it one 
must wait until repeated severe and almost uncontrollable hemorrhages 
have occurred before making the diagnosis. 

In two of the three cases x reported by me, the bleeding point was in 
the median line of the upper surface of the tongue. Hemorrhages most 
commonly occur from mucous membranes, especially of the nose and throat. 
Catarrhal diseases of the nose and throat, and diseases of the gums, may 
precipitate serious and even fatal hemorrhages. Bleeding may also occur 
from the bowels, the stomach, any portion of the skin, and, in fact, from 
any part or into any organ of the body. Subcutaneous hemorrhages pro- 
ducing hematomas are common. These hematomas may be very large, 

1 Medical News, 1892. 



TREATMENT 539 

and may be associated with fever and gastrointestinal symptoms. Hemor- 
rhages into the skin may produce ecchymotic spots, which may lead to some 
confusion in the diagnosis of this disease from purpura. The ecchymoses, 
however, in hemophilia are large, irregular in shape, and not, as a rule, 
widely distributed. 

Arthritis occurs, sooner or later, in almost every case. The knees 
and elbows are most commonly involved, but the smaller joints may also 
be affected. The swelling occurs rapidly and is produced by hemorrhage 
into the joint from the synovial membrane. In the beginning there is no 
tenderness, redness, or inflammation, although pain may be present as a 
result of the tension. The inflammatory stage quickly follows, during 
which the joint is somewhat tender and red, showing a subacute inflamma- 
tion. From this injury the joint may entirely recover, or permanent anky- 
losis may result. Fever and pain may accompany the joint symptoms, but 
they are not so pronounced, nor so transient in character, as they are in the 
arthritis associated with purpura. 

Pronounced anemia and great exhaustion follow the long-continued 
hemorrhages that occur in these cases. The microscopic blood picture is 
that of severe secondary anemia. The pulse becomes rapid and thready, 
the patient is nervous, faint, and complains of shortness of breath and 
great exhaustion. If the hemorrhage is controlled the patient slowly 
convalesces, perhaps to suffer from another attack, to which he succumbs 
from exhaustion. 

Diagnosis. -In the vast majority of instances the family history, the re- 
peated hemorrhages, and the subacute arthritis make the diagnosis plain. 
In rare instances, however, the occurrence of a purpuric rash with these 
symptoms, and the absence of a family history of hemophilia, may make 
the differential diagnosis between this condition and purpura hemorrhagica 
a very difficult matter. 

Prophylaxis. —The members of hemophiliac families should be advised 
against marriage. This applies especially to the females, since it is 
through them the disease is most likely to be transmitted. The children 
of these families should, during infancy and young childhood, be most 
carefully guarded from injury, and should, if possible, live in a warm 
climate, since mild, semitropical climates sometimes exercise a decidedly 
protective influence against the hemorrhages of this disease; it is possible 
that the beneficial results of a warm climate are due to the comparative 
freedom which such a climate offers from catarrhal diseases of the nose 
and throat. As a prophylactic measure the gums and mucous membranes 
of the mouth should be carefully washed every day with a simple alkaline 
antiseptic, and all surgical measures of every kind, including the pulling 
of teeth and circumcision, should be carefully avoided. 

Treatment. —In the treatment of an attack the control of the hemor- 
rhage demands first consideration. Long-continued compression of the 
bleeding part is the most valuable measure. Adrenalin, a sterile solution 
of gelatin, and perchlorid of iron may be used with compression. The 



540 HODGKIN'S DISEASE 

great difficulty in most instances is to reach the bleeding point in such a 
way that these measures may be satisfactorily employed. In one of the 
cases reported by me, the tongue was compressed by a clamp, which held 
a small piece of cotton, saturated with MonselPs solution, against the 
bleeding point on its anterior surface. The grasp of the instrument was 
now and then slightly relaxed to allow better circulation in the tip of the 
tongue. After two hours of such treatment the clamp was removed and a 
hemorrhage which had lasted for five consecutive days was controlled. 

Calcium lactate in 5- to 15-grain doses, depending upon the age of 
the child, should be given three times a day for a period of four or five 
days, or until the hemorrhage is controlled. A number of observers have 
reported good results from this remedy, and have recommended that it 
be given at least one day in every week in the subsequent treatment of 
these cases. 

Serum Treatment. — Eecent reports indicate that standardized ani- 
mal blood serum is a valuable remedy in stopping the hemorrhage and in 
controlling, at least temporarily, the hemorrhagic tendency. It is to be 
injected in doses of 10 to 20 c. c, and this dose repeated, if necessary, 
every second day until 100 c. c. have been given. The local application of 
the serum to bleeding mucous membranes is also recommended for con- 
trolling hemorrhages. If a simple standardized sheep or other animal 
serum is not available, one may use antistreptococcic serum. Ten c. c. of 
normal human serum, when it can be had, is a safer and more efficacious 
remedy. Direct transfusion of human blood has been successfully used 
in the treatment of the hemorrhagic diseases of infancy and childhood. 
These remedies may not permanently remove the cause of the disease, al- 
though they produce great temporary benefit by restoring the impaired 
blood coagulability. 



CHAPTEE LXVIII 

HODGKIN >S DISEASE 

Hodgkin's disease, also described under the synonyms adenie, lymph- 
adenoma and pseudoleukemia, is characterized by a progressive, painless 
enlargement of lymph nodes, usually beginning in the neck, associated 
with a progressive anemia and frequently with the formation of nodules 
in the spleen and other internal organs. 

Etiology. — Nothing is known of the causes of this disease. Tubercu- 
losis is not infrequently associated with it as a secondary infection. It 
occurs most commonly in childhood and early adult life, is not infre- 
quent in the second and third decades, but is comparatively rare after 
forty. 

Pathology. — A symptom-complex closely resembling Hodgkin's disease 
may be presented by other pathological processes, such as lymphosarcoma, 



DIAGNOSIS 541 

but the term should be confined to a chronic inflammatory process which 
produces an enormous enlargement of lymph nodes, and results in the 
deposit of lymphatic nodules in the spleen, liver, subcutaneous tissues, 
and other parts of the body. The exciting cause of this progressive 
chronic inflammatory process is not known, but the microscopical changes 
produced are the same as in other chronic inflammations. 

Symptomatology. — Genekal Symptoms. — Enlargement of lymph nodes 
beginning, as a rule, in the posterior triangle of the neck, is the charac-, 
teristic symptom. It may rarely begin in the inguinal, axillary, medi- 
astinal, or other lymph glands. The enlargement of these nodes produces 
painless tumor masses which spread by continuity to neighboring glands 
on the same or opposite sides of the neck or into the mediastinal or axillary 
regions, in this way producing enormous tumor masses, which are firm, 
hard and nodular, but are freely movable, and show no tendency to sup- 
puration. The disease may be uniformly progressive, or there may be 
periods of apparent quiescence followed by periods of rapid growth. As 
it progresses, pressure symptoms may result from these large tumors, 
impinging on the trachea, bronchi, blood vessels, nerves, bile ducts, ureters 
and other tissues. There is progressive anemia, weakness, and cachexia. 
The gradually increasing dyspnea, which may end in strangulation, is the 
most terrible of all these pressure symptoms. 

The spleen is moderately enlarged in a majority of the cases, and the 
liver may also be increased in size. Nodular masses in the subcutaneous 
tissues may occur. 

The fever is very variable; afebrile cases may occur; as a rule, there 
is a low continued fever, rarely rising above 103 °F., which continues for 
months ; in other instances it may be intermittent, and in those eases, with 
periods of apparent quiescence, there may be periods in which the tem- 
perature is normal, followed by periods of severe pyrexia, during which 
there is a rapid progression of the disease. 

Blood Changes. — The only important blood change which occurs in 
this condition is a simple secondary anemia, caused by an almost equal 
reduction in hemoglobin and red blood corpuscles. This anemia is 
progressive, and as the disease advances becomes extreme. In the last 
stages there may be less than 30 per cent, of hemoglobin and less than 
2,000,000 red blood corpuscles per c. mm. The leukocyte picture is prac- 
tically normal; there may, however, be a slight leukocytosis of 15,000 
or 20,000. 

Diagnosis. — In lymphosarcoma the disease does not confine itself to 
the lymphatic glands, so that the tumor mass is softer and the nodules 
less clearly defined than in Hodgkin's disease. When in doubt, a micro- 
scopical examination of one of the superficial lymph nodes removed from 
the mass will definitely determine the character of the growth. 

Tuberculosis may rarely produce large, painless lymphatic tumors of 
the neck, which may grow in size and extend from node to node over a 
period of months, without showing any tendency to break down. These 



542 SIMPLE ADENITIS 

cases may be confused with Hodgkin's disease, but, as a rule, the diagnosis 
can be made by the tuberculin skin reaction, and by other symptoms of 
lymph-node tuberculosis. The examination of a superficial lymph node 
removed from the mass will establish the diagnosis. 

From leukemia and secondary anemias with splenic enlargement this 
disease may be differentiated by the blood examination. The so-called 
pseudoleukemia of infancy bears no resemblance whatever +o this disease. 

Prognosis. — The disease is probably always fatal, usually terminating 
within two years, but patients may live for four or even five years. Death 
may occur from tuberculosis, secondary anemia, septic or other infections, 
or from the pressure of the tumor masses on vital structures. 

Treatment. — There is no treatment that exerts any curative influ- 
ence. The removal of the tumor masses by surgical measures may give 
temporary relief from pressure symptoms, but has no influence on the prog- 
ress of the disease. Arsenic has been in general use for a long time in 
the treatment of this condition. It should be given in large doses over 
long periods of time, and the consensus of opinion is that it some- 
times diminishes the size of the tumors, and frequently causes a temporary 
cessation in their growth. It exerts no curative action, and probably has 
little influence in prolonging life. 

The X-ray, at the present time, is the remedy most in vogue in the 
treatment of this condition. Under its use the large lymphoid tumors may 
diminish in size, and in some cases almost disappear. When the treat- 
ment is discontinued, however, the tumor masses reappear. This treat- 
ment, therefore, has no curative influence. It is believed, however, that 
if the X-ray is used to reduce the size of these lymphoid masses when they 
become large or exert uncomfortable or dangerous pressure symptoms, the 
life of the patient may be made more comfortable, and may, perhaps, be 
prolonged. 



CHAPTER LXIX 
SIMPLE ADENITIS 

Simple adenitis is an inflammation of lymph nodes not produced by 
tuberculosis or syphilis. It is not a distinct disease, but a secondary 
condition due to infection with pathogenic microorganisms, commonly 
the pyogenic cocci, which have found their way from nearby inflammatory 
processes in direct communication with the infected nodes. The pyogenic 
infection thus produced results in an acute inflammation and general hy- 
perplasia of the gland tissue, which may subside without suppuration, 
but which, especially in infancy, very commonly results in the breaking 
down of the lymph nodes, and more or less involvement of the surround- 
ing cellular tissue, with the final discharge of the abscess through the 
skin or into some cavity of the body. 



SYMPTOMATOLOGY 543 

The deep cervical lymph nodes are by far the most commonly affected, 
since they are in direct communication with the mucous membranes of the 
pharynx, nose, throat and mouth, so commonly the sites of disease in 
the child. These glands become affected in tonsillitis, pharyngitis, in- 
flammation of the adenoids and rhinitis. The submaxillary glands are en- 
larged in stomatitis and ulcerated teeth. 

The superficial cervical lymph nodes are commonly enlarged from 
eczema of the scalp and face, or from infected wounds of these regions. 

Simple adenitis of other lymph nodes of the body is less common. 
The inguinal nodes may be affected from vulvovaginitis in infancy and 
from other local inflammatory processes in that region. The axillary 
lymph nodes are commonly inflamed as the result of vaccination, and may 
be enlarged from other infected wounds of the upper portion of the arms. 
Adenitis of the bronchial lymph nodes is associated with disease of the 
lungs and smaller bronchi, and the deep-seated abdominal lymph nodes 
may become affected in gastroenteritis and other diseases of the enteric 
canal. Certain of the acute infections, especially influenza, scarlet fever, 
diphtheria, and measles, are almost always associated with more or less 
enlargement of lymph nodes. The adenitis, however, which is produced 
by the acute infections and by disease of the lungs and gastroenteric canal, 
as well as that which results from tuberculosis and syphilis, is discussed 
in connection with these diseases. It only remains, therefore, for us to 
call attention very briefly here to the fact that simple adenitis, especially of 
the cervical glands and more rarely of the inguinal and axillary glands, 
occurs in young children, as the result of some simple nearby inflamma- 
tory process, and that the adenitis in these cases may be so severe that 
the causative condition may almost be lost sight of in the symptom group 
that follows. 

Age is a most important predisposing factor of simple adenitis. The 
great majority of the cases occur under two years of age. The younger 
the child the greater the probability that the resulting inflammation will 
end in suppuration. 

Symptomatology. — The enlarged lymph nodes are readily seen and 
felt. They appear as hard, painful", tender masses, round or oblong in 
shape, in the subcutaneous tissues or beneath the superficial muscles. 
Neighboring nodes may be so agglutinated by the accompanying cellulitis 
that a large tumor mass may form, in which the individual nodes may be 
lost. Fever is present during the acute stage and lymphocytosis develops. 
As the inflammation proceeds the overlying skin becomes red, and if sup- 
puration occurs, as it frequently does in infancy, a softening of the in- 
flamed glands may be felt. The abscess points and finally breaks through 
the skin, and with the discharge of pus the inflammation quickly subsides 
and the wound heals. In the great majority of cases, and this is espe- 
cially true in children over two years of age, the tender, tumor-like mass, 
large or small, after the second or third week gradually diminishes in 
size, loses its tenderness, and the individual nodes which were formerly 
36 



544 SIMPLE ADENITIS 

lost in the tumor mass may now be made out. In the majority of in- 
stances these glandular swellings gradually disappear, so that a return to 
normal conditions may be expected in from four to six weeks. If, how- 
ever, the source of irritation which originally caused the lymph node en- 
largement continues, a simple chronic adenitis may result. In these 
cases the lymph nodes may remain enlarged for many months, but the symp- 
toms are much less pronounced than in the acute form above described. 

In simple bronchial and abdominal adenitis the diagnosis may be con- 
firmed by radiographs and by the same physical signs, which have been 
detailed in the chapter on tuberculosis. 

Diagnosis. —The diagnosis of syphilitic and tuberculous adenitis has 
been carefully considered elsewhere, and if these symptom groups are kept 
in mind there should be no difficulty in making a differential diagnosis 
of simple adenitis. It may be noted here, however, that the presence of 
a local exciting cause, such as disease of the mucous membranes of the 
nose, mouth or throat, vaccination or vulvovaginitis, may speak in favor 
of a simple adenitis, and also that, under two years of age, simple adenitis 
is much more common than tuberculous adenitis, and much less common 
after this period of life. The diagnosis, however, is usually made by ex- 
cluding tuberculosis and syphilis by reason of the absence of the charac- 
teristic symptom-complexes of these diseases. 

Treatment. — In every instance the cause of the adenitis should be 
sought and treated. Most of these cases are dependent upon diseases of 
the lymphoid tissues of the pharynx. The most important part of the 
treatment, in such cases, is the careful treatment of all catarrhal conditions 
of the nasopharynx. Inunctions of unguentum Crede and guaiacol * into 
the tissues surrounding the enlarged lymph nodes are of great value and 
should be resorted to in all severe cases. The technique of this treatment 
is given in the chapter on Scarlet Fever. Cold compresses are of value 
in many cases. When abscess formation can be definitely made out, an 
incision should be made and the pus evacuated. In subacute and chronic 
cases, where the glands remain large and tender with no tendency to sup- 
puration, the application of flexible collodium, as recommended by Forch- 
heimer, by exerting a steady pressure upon these glands, promotes their 
absorption. Iron and iodin tonics are of value. In older children the 
freshly prepared syrup of the iodid of iron is followed by good results. 
In all cases fresh air and properly selected food are almost of as much 
value as they are in the treatment of tuberculous adenitis. 

x See Tuberculosis. 






ANATOMY AND PATHOLOGY 545 

CHAPTEE LXX 
STATUS LYMPHATICUS 

Status lymphaticus is characterized by a hyperplastic enlargement of 
the thymus gland and other lymphoid structures. This lymphatic hyper- 
plasia is commonly associated with a lowered vitality, a chloranemia, and 
a well-marked dyspnea, which may be aggravated into pronounced asth- 
matic attacks or end in sudden death. 

Anatomy and Pathology. — The thymus is a ductless gland composed 
of lymphoid tissues, holding remnants of the epithelial structures which in 
early life predominated in its makeup. It consists of two lobes joined 
together in the median line. It is situated behind the upper portion of 
the sternum occupying the superior strait of the anterior mediastinum. 
Below, it rests upon the pericardium and extends upward over the great 
vessels of the heart into the neck, resting on the trachea as far up as the 
thyroid gland. Laterally it is in contact with the vagi, the phrenic 
nerves, the innominate and common carotid arteries. Its association, 
however, with the trachea in the narrowest portion of the chest, between 
the manubrium sterni and the spinal column, is of special pathological im- 
portance, since enlargement of the gland in this narrow confined space 
must necessarily contract the lumen of the trachea. It is relatively large 
in infancy and early childhood, and slowly increases in size up to the 
fifteenth year, after which regressive changes slowly take place which 
diminish its size and physiological efficacy. The size of this gland varies 
greatly in different individuals of the same age. Warthin accepts 7 grams 
as the average weight in the new-born, and 15 grams as evidence of a 
hyperplastic condition of this organ. It is generally believed that the thy- 
mus furnishes an internal secretion which exerts an important influence 
on nutritional processes, and especially, as the writer believes, on the func- 
tional efficiency of all lymphoid tissues. Its period of greatest functional 
activity is during fetal life and early childhood. This function diminishes 
most rapidly after the fifteenth year, but probably remains more or less 
active throughout life. Svchla offered the theory that hyperthymization 
was the important cause of status lymphaticus. 

The most important pathological condition in status lymphaticus is 
a true hyperplasia of lymphoid tissues, most marked in the thymus gland. 
This gland may be greatly enlarged, weighing forty or fifty grams, 
and, according to Warthin, there may also be a congestion or edema which 
further increases its size and leads to pressure upon the trachea and 
other important structures held in the narrow, closely confined and un- 
yielding space beneath the upper part of the sternum. The enlargement 
of the spleen, tonsils, adenoids, lymphatic glands, and lymphoid tissue in 
general, so commonly associated with the enlarged thymus, is also hyper- 
plastic in character. There is hypoplasia of the general arterial system; 



546 STATUS LYMPHATICUS 

marked blood changes occur and the heart muscle may be weak and dilated. 
Eachitic and syphilitic changes are present in some of the cases. 

There is no doubt that enlargement of the thymus may by compress- 
ing the trachea produce dyspnea and violent attacks of asthma. This is 
proven by the fact that these symptoms may be relieved either by extirpat- 
ing the enlarged thymus, or by inserting into the trachea beyond the point 
of constriction a long intubation tube. It does not follow, however, that 
these symptoms may not in other cases be produced by pressure on other 
tissues or by toxins, or by hyperthymization (Svchla). 

Symptomatology. — The most important symptom and the one that usu- 
ally calls attention to the condition is the dyspnea, which may vary in 
severity from a mild stridor to a violent attack of asthma terminating in 
the death of the infant. A severe spasmodic cough almost always accom- 
panies this stridor. The cough may produce vomiting, be associated with 
cyanosis and greatly aggravate the dyspnea, precipitating at times severe 
asthmatic attacks. 

Thymic asthma is an exaggeration of the thymic dyspnea or stridor. 
The first difficulty in breathing associated with an irritable or spasmodic 
cough usually makes its appearance in early infancy, sometimes soon after 
birth. These symptoms may disappear and reappear from time to time, 
perhaps gradually increasing in severity, over a period of months and even 
years, until the disease becomes so advanced that asthmatic attacks are 
precipitated by indigestion, influenza, slight catarrhal conditions in the 
nose or bronchial tubes, or by any pathological condition which irritates 
lymphoid tissues. In severe cases, throwing the head backward may pro- 
duce a violent asthmatic attack. As the disease progresses these asthmatic 
attacks become more violent and recur without apparent cause, severe 
dyspnea being almost continuous. In these cases marked cyanosis and 
temporary suspension of breathing may threaten suffocation; sudden death 
may occur. 

Sudden deaths in infancy from slight or unknown causes are commonly 
due to the status lymphaticus. Deaths from slight surgical operations, 
such as the removal of adenoids, and circumcision, and from slight in- 
juries or from sudden shock, such as coming in contact with cold water, 
as in bathing, may be of this character. In some instances death may oc- 
cur without apparent cause; the child may be playing about when sud- 
denly it becomes cyanotic, slightly convulsed, and quickly dies of respira- 
tory failure, or it may be found dead in bed. These latter cases no doubt 
include some of those thought to be due to "overlaying." The exact 
modus operandi of these deaths is not understood, and just what role 
hyperthymization and pressure on the trachea, the pharynx, or pneumo- 
gastrics play is yet to be decided. In perhaps most of these cases a diag- 
nosis might have been made if the disease had been suspected and the 
patient subjected to a careful examination during life. It should also be 
remembered in this connection that sudden death in infants may occa- 
sionally occur from causes entirely apart from the status lymphaticus. 



SYMPTOMATOLOGY 547 

Laryngeal spasm and acute pulmonary congestion are among such causes. 

Sudden deaths from anesthesia in infancy and childhood are almost 
always due to this cause, and the diagnosis in most of these cases is made 
on the post-mortem table, by the finding of an enlarged thymus, a weak 
and dilated heart muscle, and perhaps other signs of the status lymphaticus. 
Chloroform is considered more dangerous than ether in these cases. When 
the importance of this subject is fully realized by the surgeon and gen- 
eral practitioner, and every child before being given an anesthetic is care- 
fully examined for evidences of the status lymphaticus, then death from 
anesthesia in childhood will be extremely rare. 

Enlargement of the Thymus. — If attention is directed to the possible 
presence of this condition by an unexplained chronic dyspnea or general 
enlargement of lymphoid tissues, enlargement of the thymus, which is the 
most characteristic sign of this disease, may be demonstrated by physical 
examination. Blumenreich says that the dullness on percussion produced 
by the normal thymus gland is in the shape of a triangle, whose base is a 
line drawn between the sternoclavicular joints, and whose apex is the 
miclsternal line on a level with the second rib. This triangle, however, 
inclines a little to the left of the sternum at its upper margin. When 
the thymus gland is enlarged, this triangle of dullness is extended in all 
directions, but especially to the left of the sternum, and below the clavicle. 
Careful percussion will, in the great majority of cases, demonstrate en- 
largement of the thymus. Boggs says the lower border of thymic dullness 
moves upward when the head is thrown back. The enlarged gland may 
sometimes be felt in the suprasternal fossa. 

Radiography is one of the methods of demonstrating an enlarged thy- 
mus. The radiograph shows the shadow of the thymus as continuous with 
the heart shadow extending up on both sides of the sternum into the neck. 

The spleen, lymph nodes, tonsils, pharyngeal adenoids and follicles 
at the base of the tongue are commonly enlarged. Tumor masses in the 
neck or in the abdomen may be produced by the agglutination of large 
lymph nodes. Itching of the skin is a common symptom. 

A blood examination reveals a well-marked chloranemia, the hemo- 
globin being markedly reduced, the red corpuscles normal in number, but 
showing many normoblasts and poikilocytes. A marked leukocytosis is 
commonly present, and the differential count shows a great relative in- 
crease in the number of lymphocytes. In one of my cases the blood ex- 
amination was as follows: Hemoglobin, 65 to. 70 per cent.; red corpuscles. 
fresh preparation, showed considerable poikilocytosis, a few "ameboid" 
micropoikilocytes, and, on the whole, the red cells were smaller than nor- 
mal; the stained preparation showed 6 normoblasts to 500 whites counted; 
white corpuscles, 24,600; red corpuscles, 5,881,250; color index, 0.58. 
Differential count: polymorphonuclear neutrophiles, 25.6 per cent.; small 
lymphocytes, 61.8 per cent. ; large lymphocytes, 2.6 per cent. ; large mono- 
nuclear leukocytes, 8.4 per cent.; eosinophiles, 0.6 per cent,; mast cells, 
1 per cent. 



548 STATUS LYMPHATICUS 

The child is usually fat, flabby, and to the naked eye presents a well- 
marked anemia bordering on pallor. The heart is usually rapid and irri- 
table, and may be acutely dilated. These children are non-resistant, mal- 
nourished, neurotic, predisposed to convulsive disorders, and frequently 
succumb to the acute infections. 

In rare instances the thymus gland alone, of all the lymphoid tissues 
of the body, surfers hyperplasia. In such cases the symptom-complex of 
the status lymphaticus as above given is not complete, the patient suffer- 
ing only from those symptoms produced by an enlarged thymus. 

Prognosis. — This condition is fraught with many dangers. Many 
of these patients die from intercurrent diseases such as the acute infec- 
tions. Many of the deaths from anesthesia and many of the sudden deaths, 
especially in childhood, from slight or unascertainable causes are due to 
this condition. The brilliant results, however, which have recently been 
obtained by surgery and by the use of the X-rays promise to greatly dim- 
inish the mortality from this disease. It should also be remembered that 
as time goes on the natural physiological atrophy of the thymus gland 
tends to a spontaneous cure, so that in the milder cases the disease is 
gradually outgrown. 

Treatment. — It is my belief that in infants and young children Eont- 
gen rays act specifically in the control of the dyspnea and certain other 
important symptoms of status lymphaticus, and that when this method of 
treatment is judiciously used and assisted by other therapeutic measures, 
the symptoms of this disease may be controlled until time, which brings 
about gradual diminution in the size and function of the thymus, completes 
the cure. 

When the enlarged thymus gland in a case of status lymphaticus is 
exposed to the influence of the X-rays, we have, as a result of this treat- 
ment * : 

"1. Decrease in size of the hyperplastic thymus, with the disappearance 
of the cough, stridor, and asthma. 

"2. Decrease in size of the enlarged spleen and lymph nodes. 

"3. Stimulation of the physical and intellectual growth of the patient. 

"4. Eapid disappearance of the marked lymphocytosis which character- 
izes this disease. 

"5. Control of the excessive physiological action of the thymus gland. 

"The slight return of the symptoms, stridor, cough, etc., at intervals of 
three or four months, in one of my cases, and the quick control of these 
symptoms by one or two exposures to the X-rays indicate that the gradual 
regeneration of the thymus following the X-ray treatment may be accom- 
panied by a gradual reproduction of the same pathological conditions, 
hypersecretion, etc., which were present before the treatment was begun. 
Since the above remarkable results are brought about by the action of the 
X-rays on the thymus gland, it would appear that the excessive physiolog- 
ical activity of the thymus gland bears the same relationship to status 
1 The author in The American Journal of Medical Sciences, October, 1910. 



TREATMENT 549 

lymphaticus that excessive activity of the thyroid gland bears to exophthal- 
mic goiter. One seems justified in inferring from the above facts that 
the exciting cause of true status lymphaticus acts primarily on the thymus 
gland, commonly producing marked hyperplasia of this organ with an in- 
crease in or perversion of its internal secretion, and that this increased 
or perverted secretion is responsible for the general hyperplasia of lymphoid 
tissues, the lymphocytosis, and general feebleness of constitution which 
occur in this disease. This inference seems justified by the facts above 
noted, that the general hyperplasia of lymphoid structures, as well as all 
of the other symptoms of status lymphaticus, disappear when the X-rays 
reduce the thymus to normal size and, perhaps of more importance, to nor- 
mal functional activity." 

Alfred Friedlander * demonstrated experimentally that any degree of 
fibrosis of the thymus gland could be produced by the action of the X-ray 
on this gland and that a thymus thus partially involuted is capable of 
regeneration. 

In 1907 Alfred Eriedlander reported a case of status lymphaticus 
with marked enlargement of the thymus and persistent stridor. Heinecke 
(quoted by Friedlander) demonstrated the selective action of Rontgen 
rays on lymphoid tissues, including the thymus, and showed that under 
their action marked changes occurred in these tissues with a reduction in 
their size. In a case of status lymphaticus Hochsinger, by repeated ex- 
posures, decreased the area of thymic dullness and greatly improved the 
stridor. In the last few years a number of successful cases have been re- 
ported. 

The technique of this treatment in my cases was as follows : The tube 
for the passage of the X-rays had an aperture two inches in diameter, 
was enclosed in a ray-proof shield, and every portion of the body of the 
child, except the region of the thymus, was protected from the rays. In- 
jury to the skin was guarded against by filtering the rays through a 
piece of sole leather. The distance of the tube from the skin was ten 
inches and the amount of current used 1 milliampere. The character of 
the tube was high vacuum and well seasoned penetration (Walter 6). The 
exposure was directly over the thymus gland both anteriorly and posterior- 
ly; the time of exposure in beginning the treatments was three minutes; 
at the close of the treatments in the fifth or sixth week it was eight min- 
utes; from fourteen to eighteen treatments were given. During the first 
week from four to six treatments were given of three minutes each both 
anteriorly and posteriorly ; during the second week three treatments of four 
minutes each anteriorly and posteriorly ; during the third week two or three 
treatments of six minutes each anteriorly and posteriorly : during the fourth 
week no treatments were given ; during the fifth and sixth weeks two treat- 
ments of eight minutes each. 

Under this treatment the enlargement of the thymus, spleen, and 
other lymphoid tissues was gradually reduced, the dyspnea ami cough 

1 Archives of Pediatrics, October, 1911. 



550 STATUS LYMPHATICUS 

slowly improved; the lymphocytosis disappeared, and, although the chlor- 
anemia commonly remained, there was great improvement in the physical 
condition of the patient. 

No definite rules can at present be given to govern the administration 
of the Rontgen rays in the treatment of an individual case. One may say, 
however, that these treatments should be administered as above outlined 
over a period of from four to six weeks, provided the patient continues to 
improve. It is not wise, however, to continue the X-ray treatment after 
the lymphocytosis has disappeared, even though there may remain a slight 
amount of dyspnea and some cough, since these symptoms, as a rule, en- 
tirely disappear within a few weeks after the discontinuance of the treat- 
ment. The prolonged use of the X-rays in these cases may aggravate the 
chloranemia and otherwise interfere with nutritional processes. In the 
first course of X-ray treatments it is better to make the mistake of stop- 
ping the treatment too early than of continuing it too long. If it be found 
later, after an interval of some months, that the symptoms of status lymph- 
aticus are returning, two or three treatments with the rays at intervals of a 
few days will again bring these symptoms under control. In one of my 
cases it was necessary to give a number of X-ray treatments at intervals of 
three or four months over a period covering a year and a half from the 
time the first series of treatments were given. 

As an adjunct to the X-ray treatment, fresh air, nutritious and 
easily digested food, and some preparation of easily assimilated iron are 
of the very greatest importance. It is advisable early in the case to give 
some preparation of organic iron preferably combined with malt extract, 
and this should be continued long after the X-ray treatment has been dis- 
continued, or until the chloranemia has entirely disappeared. In one of 
my cases a very marked chloranemia, which remained after the discon- 
tinuance of the X-ray treatment, very quickly responded to hypodermic 
injections of neutral citrate of iron in % -grain doses given once a day. 

In the management of a case of status lymphaticus it is important to 
remember that great danger attends the giving of anesthetics, and that 
sudden shocks to the nervous system, such as result from cold baths, may 
endanger life, and that it is important to avoid all acute infections, es- 
pecially those which involve the respiratory tract, since these diseases not 
uncommonly end fatally in this class of cases. 

The amount of exercise which these patients take should be carefully 
regulated. If marked dyspnea or a dilated heart with rapid and feeble 
heart action exists, exercise not only aggravates these symptoms, but it may 
be even dangerous to life. 

If syphilis be suspected, antisyphilitic treatment should be given; 
if rickets is present, fresh air, cod-liver oil, and a proper diet should be 
prescribed. 

Surgical Treatment. — The results of thymic surgery have been un- 
usually brilliant; five cases are reported in which this treatment resulted 
in a cure. All of these cases were aggravated ones, the patient suffering 



DISEASES OF THE SPLEEN: ENLARGEMENT 



551 



from extreme dyspnea and other distressing symptoms of status lymph- 
aticus. The operation consists in the complete or partial removal of the 
thymus gland. As a result of experience it is advised that in infants and 
young children only the upper portion of the gland be removed, and that 
the lower portion be drawn up so as to lift it from its position and hold it 
by stitching to the surrounding tissues. The total removal of the thymus 
gland in young infants will, it is believed by Konig and others, interfere 
with subsequent development. At the present time, however, the indica- 
tions are that the X-ray treatment will supersede the surgical treatment 
of this condition. 

CHAPTER LXXI 

DISEASES OF THE SPLEEN: ENLABGEMENT 

In infancy the normal spleen varies in length from 4 to 6 or 8 cm. It 
extends from the mid-axillary line backward, its upper border correspond- 
ing with the ninth and its lower with the eleventh rib. 

Enlargement of the spleen is very common in infancy, and in many 
conditions it is of great diagnostic importance. One depends almost exclu- 




Fiq. 83. — Position in Palpating the Spleen. 



sively upon palpation for the diagnosis of enlarged spleen in infancy and 
childhood. At this age an enlarged spleen can be very readily felt be- 
neath the margin of the ribs in the mid-axillary line. This sign is much 
more common, much more easily made out, and of much more clinical sig- 
nificance in the child than it is in the adult. Percussion may also be util- 
ized in outlining this organ, but this method is of much greater value in the 
adult than it is in the child. When the spleen can be readily felt beneath 
the margin of the eleventh rib, it is either enlarged or displaced downward ; 



552 DISEASES OF THE THYEOID GLAND 

enlargement is very common, displacement very rare. The enlargement 
may be so great as to almost fill the abdominal cavity; this increase in 
size occurs downward and toward the umbilicus. 

The clinical significance of an enlarged spleen will depend largely upon 
the cause, and upon the symptom group with which it is associated. In 
malaria, typhoid fever, status lymphaticus, leukemia, pseudoleukemia of 
infancy, and tuberculosis (abdominal, intestinal and acute miliary), a well- 
marked enlargement of the spleen is usually present, and this sign is of 
great diagnostic value when associated with the other symptoms of these 
diseases. A moderate enlargement of the spleen, of not so much diagnostic 
value, is found in syphilis, rickets, gastroenteritis, Hodgkin's disease, sep- 
sis, amyloid disease, chronic malnutritions, anemia, heart disease, peri- 
tonitis, Banff s disease and nearly all the acute infections. 

Enlargement of the spleen produced by or associated with the above- 
named conditions is most commonly due to hyperplasia of its lymphoid 
elements. Passive congestion of the spleen may result from heart disease, 
cirrhosis of the liver, chronic peritonitis and all conditions that interfere 
with the portal circulation. Amyloid disease may be caused by suppura- 
tion and chronic bone diseases, and is associated with amyloid disease in 
other parts of the body. Inflammation of the spleen (splenitis and peri- 
splenitis) may be produced by peritonitis, syphilis, tuberculosis and 
trauma. Displacement of the spleen downward may be produced by 
pleurisy with effusion, or there may be an actual prolapsus. The latter 
condition is usually associated with a general enteroptosis of the stomach, 
liver, kidneys, etc. 

Primary splenomegaly is a rare form of splenic tumor due to a hyper- 
plasia of its endothelial cells. It occurs in early childhood and progresses 
slowly to a fatal termination, lasting for years. The condition was first 
described by Gaucher and later carefully studied by Yovaird. The splenic 
tumor gradually increases in size until it may fill the abdomen and pro- 
duce pressure symptoms of various kinds. There is marked simple anemia, 
and a pronounced hemorrhagic tendency. There may be bleedings from 
the nose and gums and subcutaneous hemorrhages may occur. 



CHAPTER LXXII 
DISEASES OF THE THYEOID GLAND 

SPORADIC CRETINISM 

{Infantile Myxedema) 

There are two varieties of cretinism, endemic and sporadic. Endemic 
cretinism, or myxedema, is due to a total or partial destruction of the 
thyroid gland caused by congenital defects or disease, commonly asso- 
ciated with a goiterous enlargement. It is endemic in certain mountainous 



SPORADIC CRETINISM 553 

districts in Switzerland, and is characterized by dwarfishness of mind and 
body and by myxedema of the subcutaneous tissues. 

Sporadic cretinism, the common and only form seen in this country, 
is due to an absence or atrophy of the thyroid gland usually congenital, 
and very rarely associated with goiterous enlargement. In rare instances 
myxedema may result from disease of the thyroid gland following acute 
infections or from the complete removal of this gland by surgical opera- 
tions. These forms of myxedema, occurring in infancy, may present a 
clinical picture similar to that of ordinary congenital sporadic cretinism, 
but these acquired myxedematous conditions are so infrequent in the infant 
that they may for practical purposes be disregarded. Sporadic cretinism 
presents a clinical picture in which, as a rule, both mental and physical 
dwarfishness are more pronounced than in endemic cretinism or myxedema 
acquired in childhood. 

Etiology. — The cause of sporadic cretinism is unknown. Heredity, 
however, is an important factor. Cases may occur in different genera- 
tions of a family, but rarely do two cases occur in the same immediate 
family. 

Symptomatology. — The characteristic symptoms of cretinism usually 
appear before the end of the first year of life; they may, however, be 
present as early as the second month, and in less pronounced cases may be 
delayed to the third or fourth year. Although the disease is usually con- 
genital, the child at birth presents no symptoms; this is perhaps due to 
the fact that up to the time of birth the child receives its thyroid secre- 
tions from the mother, and after birth, although there may be a total ab- 
sence of the thyroid body, it requires months to develop the characteristic 
symptoms which result from the absence of thyroid secretions. Because 
of its insidious onset, it is most important for the physician not only to 
keep in mind the general syndrome of this disease, but to be ever on the 
lookout for the early symptoms which announce its approach; an early 
diagnosis means success in treatment. Mental dullness is usually the first 
symptom noted; the infant is placid, torpid and presents more or less evi- 
dence of stupidity in failing to do the things which a normal child of its 
age would do. It cannot be interested in toys, or be attracted by things 
done for its amusement, and not only fails to use its arms and legs in a 
normal manner, but becomes more clumsy and less apt in this particular 
than it formerly was. This physical retrogression with an evident lack of 
intellectuality is accompanied by a vacant expression which characterizes 
the face, and there slowly develop the characteristic facies and stunted 
development of the whole body which make the diagnosis plain. The 
head is large in proportion to the body, the forehead low and narrow, 
the fontanels are open and may remain so until the child is eight or ten 
years of age; the face is broad, the cheeks heavy, the nose flat and wide, 
the eyes are wide apart and the lids may be puffy, the lips are thick and 
prominent, and the tongue, which is broad and thick, protrudes through 
the open mouth; this lolling of the tongue which may be accompanied by 



554 



DISEASES OF THE THYBOID GLAND 



drooling is a very characteristic symptom. The child teethes late, and the 
teeth are imperfectly formed and decay early. A hoarse gutteral cry may 
be one of the early symptoms. 

The hair is coarse, dry and scanty, the eyebrows are almost lacking, 
the skin of the whole body is pale, dry and cold to the touch. The sub- 
cutaneous tissues are heavy, thick, boggy, and to the touch are firm and 
resistant ; small, fatty tumors are commonly present, especially in the lower 
regions of the neck and the upper part of the back. The neck is short 
and thick and, on examination, a depression is found where the thyroid 
body should be located. There is a pronounced anterior curvature of the 

spine which produces a hollow back and 
accentuates the protrusion of the large 
and pendulous abdomen. This anterior 
curvature of the body is very pronounced 
when the child is standing, and is exag- 
gerated by the large and apparently pro- 
truding buttocks, giving this portion of 
the body a kangaroo appearance. Um- 
bilical hernia is common, the hips are 
heavy, and the legs are short and clumsy. 
These children, as a rule, do not learn to 
walk until they are four or five years of 
age, and then have a peculiar waddling 
gait, handling their bodies and arms in 
a slow and clumsy manner. The hands 
are thick, short and spadelike; the hy- 
pothenar eminence is especially promi- 
nent; the fingers are short, blunt and 
heavy. 

As the child grows older the dwarfed 
gftl^ § mm, appearance of the whole body becomes 

Wk > , more pronounced; a cretin of twenty may 

not be more than four feet in height, and 
with this lack of physical development 
there is a corresponding lack of mental 
development. It may not be able to speak and may not have sufficient 
intelligence to avoid uncleanly habits in urination and defecation. A 
state of absolute idiocy is present in most of these cases. Troublesome 
constipation is not an unusual symptom; anemia is present, but the blood 
examination shows nothing characteristic. The temperature is subnormal, 
registering 95 or 96 in the rectum. The sexual organs are late in their 
development. 

Differential Diagnosis.— There are few diseases that present to the eye 
so repulsive and so characteristic a picture as cretinism; when once seen 
it is rarely, if ever, forgotten. It can scarcely be confused with any other 
condition, except, perhaps, Mongolian idiocy. In this condition, however, 




Fig. 84. — Typical Cretin; Age 
Four Years. 



SPOKADIC CRETINISM 



555 



the slanting eyes and the Mongolian type of face, the soft smooth skin, 
the soft, straight, normal hair, the small brachycephalic skull, and the 
absence of swelling in the tongue and lips should suffice to make the diag- 
nosis plain. If in doubt, however, the therapeutic test will definitely dif- 
ferentiate the two conditions; Mongolian idiocy does not respond to the 
thyroid therapy. 

Thyroid Insufficiency. — While the diagnosis of ordinary cretinism pre- 
sents but few difficulties, it should be remembered that there are a much 
greater number of cases in which there are degrees of thyroid insufficiency 
varying from a condition in which the thyroid insufficiency is so slight that 
it produces few or no characteristic symp- 
toms to the condition, above described, 
of true cretinism in which the thyroid 
gland is congenitally absent or atrophied. 
These cases of thyroid insufficiency pre- 
sent in a modified form and milder de- 
gree the symptoms of cretinism. They 
are undersized and underweight, are lack- 
ing to a greater or less degree in mental 
development, and are grouped in the 
schools with the "backward" children. 
As a rule, they have subnormal tempera- 
tures. 

Prognosis. — The earlier the diagnosis 
the better the prognosis. If treatment is 
begun during the first year of life, the 
child's physical development may be per- 
fect, and its mental development will be 
almost, but, perhaps, not quite, normal; 
yet, on the whole, the result in these 
cases is satisfactory, since they may be- 
come useful members of society, attain- 
ing a fair degree of intellectual develop- 
ment and acquiring sufficient education 
to enable them to follow some useful avo- 
cation. If the treatment is begun later 
in the life of the child the results, while striking, are not so satisfactory, 
and even in cases where the treatment is begun as late as puberty, marked 
physical and mental improvement may result, but these cases can never be 
benefited sufficiently to make them self-supporting. Untreated cases re- 
main hopeless, repulsive idiots. 

Treatment. — In the whole range of medicine there is no more remark- 
able example of the marvelous curative effect of a therapeutic measure than 
is furnished by the thyroid treatment of cretinism. In this treatment we 
have a brilliant example of true specific medication. Previous to the dis- 
covery of the specific action produced by feeding the thyroid gland to 




Fig. 85. — Same Cretin; Age 
Twelve, after Eight Years 
of Treatment. 

She is now fourteen years old and 
is holding her own in the 5th 
grade of the Cincinnati pub- 
lic schools. The average age 
of the pupils of her grade is 
about four years younger. 



556 DISEASES OF THE THYEOID GLAND 

cretins, these patients were absolutely beyond the reach of medical treat- 
ment; they remained hopeless and helpless imbeciles, fortunately dying 
of some intercurrent disease before middle life. At the present time, un- 
der thyroid treatment, they are slowly transformed into comparatively 
normal individuals. A cretin that came to me at the age of four years, 
and who has been constantly under treatment for the last eight years, 
has, as shown by the accompanying photograph, a fair degree of physical 
and mental development. At fourteen years of age she is holding her 
own in the fifth grade of the Cincinnati public schools. The average age 
of the pupils of her grade is four years younger. 

Desiccated thyroids in tablet form are now universally used. They 
are put up in five-grain tablets, each containing one to two grains of des- 
iccated thyroids. Whatever make of tablet is selected for the treatment 
of a case, the same should be continued throughout. The dose for an in- 
fant under one year of age is % grain two or three times a day; it is 
rarely necessary to give more. For children three or four years of age 
the initial dose may be 1 grain, and it may be necessary to increase this 
to 2 grains. It is my belief that much harm may be done by giving too 
large doses. The most satisfactory results are obtained by the long-con- 
tinued use of small doses. If the child fails to respond to the above dosage, 
or if the progress in its physical and mental growth at any time comes to 
a standstill, then the dose should be gradually and carefully increased. 
If at any time in increasing the dosage the child shows symptoms of thyroid 
intoxication, the treatment is to be discontinued for a veek or ten days 
until these symptoms have entirely subsided. Thyroid intoxication is indi- 
cated in the young child by pallor, rapid heart action, general nervous 
irritability, and in older children by headache; fatal syncope may occur. 
In a case which I saw in consultation over a number of years, very satis- 
factory progress was made with small doses of desiccated thyroid. The 
physician, however, yielding to the importunities of the parents, gradually 
increased the dose until a very severe thyroid intoxication was produced, 
from which the child never recovered, dying shortly afterwards. In the 
treatment of these cases, therefore, the physician must be satisfied with the 
slow and gradual improvement which follows moderate size doses ; otherwise 
he may learn by experience the important lesson that these children can 
be seriously injured by overdosing with thyroid. I have rarely found it 
necessary in the treatment of any case to give more than 6 grains of des- 
iccated thyroid in a day, and it has been my experience that the dose which 
has been found effective in the treatment of the condition in the individual 
child is the close that should be continued ever afterward to prevent a re- 
turn of this condition. In the cases that I have had under observation 
for six or seven years the treatment has never been interrupted in any 
case for more than two or three weeks at a time, and this, I think, should 
be the rule throughout life. 

Other treatment may, perhaps, be of little avail, yet it has been my 
custom in recent years to use iodin and calcium in the treatment of 



THYROID INTOXICATION" 557 

cretinism. The iodin may be given in the form of syrup of hydriodic acid 
in y 2 - to 1-drachm doses, or as iodonncleoids in 1- or 2-grain doses. Cal- 
cium may be used in the form of an elixir of the glycerophosphates of 
lime and soda in from y 2 - to 1-drachm doses, or in the soluble lactate in 1- 
to 3-grain doses. The iodin and calcium medication may alternate, or 
from time to time may be interrupted. I believe that by the use of these 
drugs better therapeutic results are obtained than by the use of the 
thyroid extract alone. The change in prescriptions also serves the excel- 
lent purpose of keeping up the interest of the mother and patient in the 
medical treatment, which, if confined to the thyroid alone, after a time 
becomes monotonous and may lead the mother to conclude that, if no 
other medical treatment is to be given, she can continue the thyroid treat- 
ment herself without medical supervision. 

THYROID INTOXICATION 

The thyroid gland is one of the organs which has its greatest func- 
tional activity during the early years of life. It furnishes a secretion 
which exercises such a controlling influence over the body chemistry that, 
without it, normal growth and development cannot be carried on. This 
function of the thyroid is so nicely adjusted to the needs of the organ- 
ism that, as a rule, it furnishes this secretion in quantity and quality 
accurately adjusted to the purposes it is to serve. In a few instances, 
however, this gland is congenitally absent ; in others its functional capacity 
is diminished or destroyed by disease or accident; the resulting conditions 
are known as cretinism and myxedema. 

On the other hand, from an increased functional capacity of the thy- 
roid gland we may have an excess of its secretions poured into the body 
media, producing a well-known group of nervous symptoms. This symp- 
tom group may be produced experimentally in man by feeding excessive 
quantities of thyroid. It is sometimes observed from overdosage in the 
treatment of cretinism, and it may be observed in exophthalmic goiter, the 
symptoms of which are at least in part produced by thyroid intoxication. 
This symptom group is characterized by headache, general nervous irri- 
tability, rapid and at times irregular heart action, pallor, cyanosis, great 
bodily weakness, and a sense of precordial distress. It is my belief that 
this symptom group in a modified form very commonly occurs in rapidly 
growing children, and while it may be associated with a slight enlargement 
of the thyroid, it is in no way related to disease of the thyroid gland or 
to the development of exophthalmic goiter, later in life. It is simply a 
thyroid intoxication due to the overaction of this gland. We know that 
thyroid secretions increase the excitability and stimulate the growth and 
functional development of the nervous system. It seems very probable, 
therefore, that since childhood is the period of life when great thyroid 
activity is an important factor in producing the rapid growth and func- 
tional development of the nervous system, it may, when slightly over- 



558 DISEASES OF THE THYROID GLAND 

active, so stimulate the nervous system as to produce functional nervous 
disorders. It may, and undoubtedly does, happen that the amount of thy- 
roid secretion varies with the individual child, and when the secretion is 
excessive it may produce too rapid growth and development of the nervous 
system, accompanied by nervous irritability, mental precocity, tachycardia, 
headache, and other nervous symptoms so commonly observed in the rapid- 
ly growing child. If to this symptom group is added a slightly enlarged 
thyroid, the diagnosis of thyroid intoxication may be made. 

Treatment.— The recognition of this condition is important. It is 
transitory, and, after a time, nature adjusts the amount of thyroid secre- 
tion more nicely to the wants of the body, and with this adjustment the 
rapid growth and nervous symptoms disappear. During the period, how- 
ever, of the thyroid intoxication these children should be protected from 
overwork, both mental and physical, and in their home life and amusements 
they should be placed under conditions that will not exaggerate nervous 
irritability. It may be necessary for a time to remove them from school 
and to place them under quiet surroundings, which will in no way excite 
their nervous systems. The bromids may be of value, but the coal-tar 
preparations are contraindicated in the treatment of this condition. 



SECTION X 

DISEASES OF THE UROGENITAL SYSTEM 

CHAPTEE LXXIII 

THE UEINE 

The medical profession has long been fully impressed with the necessity 
for routine urine examinations in older children, so that this secretion has 
been studied quite as carefully in the older child as in the adult. Fre- 
quent and careful urine examinations in scarlet fever, diphtheria, in- 
fluenza, and other infections, and especially in convulsive and other nerv- 
ous disorders of childhood, have long been recognized as of the greatest 
importance. 

The difficulty, however, of obtaining specimens of urine from infants 
has been a great barrier to its systematic study both in the well and in 
the sick baby. In recent years medical men have come to realize, more and 
more, the necessity for routine urine examinations in the infant, and many 
careful investigations have added greatly to our knowledge. These investi- 
gations have shown that serious kidney lesions are less common in the infant 
than they are in the child, but they have also demonstrated that many here- 
tofore obscure diseases of the genitourinary organs of the infant can be 
satisfactorily diagnosed only by an examination of the urine. 

The following methods have been recommended for collecting the urine 
of infants : a wide flat sponge, or absorbent cotton, may be held over the 
external urinary organs by the diaper, and the urine squeezed out of these 
following urination; a wide-mouthed bottle, or rubber pouch, may be fas- 
tened over the external urinary organs with adhesive plaster, this latter 
method being more satisfactory with the male than with the female infant. 
Chapin's infant urinal, which is one of the best of a number of devices de- 
signed for this purpose, may be fastened over the external genitalia of both 
male and female infants. When the emergency demands it, catheterization 
may be resorted to with a small soft rubber catheter — No. 6, American scale ; 
but if the physician has the cooperation of an intelligent nurse, the urine 
in the great majority of instances may be caught in a suitable vessel as it 
is expelled from the bladder. 

Quantity of Urine. — The infant and young child take from four to six 
times more fluid per kilogram of weight than does the adult, and pass 
37 559 



560 THE URINE 

a correspondingly larger quantity of urine. There may be very great 
variation from hour to hour and from day to day in the quantity of urine ; 
the amount depending not alone upon the number of ounces of fluid taken, 
but also upon unexplainable and uncontrollable nervous influences, which 
may markedly inhibit the quantity one day, and greatly increase it the 
following day. These fluctuations, especially in young infants, may have no 
special pathological significance. One may say that from a pathologi- 
cal standpoint the younger the child the less important are these vari- 
ations. In older children they may indicate, as they do in the adult, an 
unstable and irritable condition of the nervous system, which in the infant 
is the normal physiological condition, but in the older child and adult 
is pathological and commonly due to hereditary or nutritional defects of the 
nervous system. It is important to remember that suppression of urine 
(anuria) may occur in infants and young children, and may last over a 
period of twelve or even twenty-four hours, without indicating a serious 
pathological condition ; in many such instances, the urinary secretion is re- 
established without one being able to ascertain the cause of the suppres- 
sion, but in older children such marked functional disturbances are com- 
monly due to organic disease, although they may be due to such profound 
functional nervous disorders as hysteria. The following table from Reusing 
shows the remarkable physiological variations which may occur in the uri- 
nary secretion of the healthy infant : 

Minimum Maximum 

In the first 24 hours after delivery 2 c. c. 61 c. c. 

2nd day 11 c. c. 145 c. c. 

3rd day 13.3 c. c. 171 c. c. 

4th day 17.5 e. c. 179 c. c. 

5th day 22.5 c. c. 222 c. c. 

6th day 70 c. c. 280 c. c. 

7th day 93 c. c. 338 c. c. 

8th day 100 c. c. 331 c. c. 

The variability in the daily quantity of urine in the infant and young 
child makes it difficult to compile a table which represents with accuracy 
the average amount of urine passed. Many careful investigations have 
been published giving widely varying results. The following table from 
Jennings is "compiled from the studies of Holt, Churchill, Morse, and 
other observers," while the carefully prepared tables of Holt, referred to, 
include the observations of Camerer and other German and French writers : 

Age Amount in 24 hours Specific gravity Urea 

First week 3 to 90 c. c. 

Third month 

Sixth month 

Ninth month 

First year 

Second year 

Third year 



90 c. c. 


1.010 to 


1.004 


0.07 


to 


0.66 


grams 


200 c. c. 


1.004 " 


1.010 


1.4 


t i 


2.3 


n 


250 c. c. 


1.006 " 


1.012 


5.0 






a 


300 c. c. 


1.006 " 


1.012 


7.0 






it 


400 c. c. 


1.006 " 


1.012 


11.0 






it 


450 c. c. 


1.006 " 


1.012 


12.0 






it 


500 c. C 


1.006 " 


1.012 


13.0 






it 



LITHUEIA 561 

Age Amount in 24 hours Specific gravity Urea. 

Fourth year 550 c. c. 1.008 to 1.016 13.5 grams 

Fifth year 600 c. c. 1.008 ' ' 1.016 14.0 

Sixth year 650 c. c. 1.008 " 1.016 15.0 

Seventh year 700 c. c. 1.008" 1.016 16.0 

Eighth year 800 c. c. 1.008" 1.016 18.0 

Ninth year 900 c. c. 1.010 ' ' 1.020 19.0 

Tenth year 1000 c. c. 1.012 ' ' 1.020 20.0 

Frequency of Urination. — Physiological incontinence is the normal 
condition in infancy. At this time of life urination is purely a reflex act. 
In the new-born it may not occur on the first or even on the second day, 
but beginning with the second day the infant usually passes urine two or 
three times in twenty-four hours, and thereafter, day by day, this increases 
in frequency until within a few weeks it may be passing urine at hour 
or even half-hour intervals. After the third month these intervals are 
gradually prolonged, so that by the end of the second year the bladder of the 
normal infant may retain urine for from two to four hours, and during 
sleep even longer. A fair degree of physiological control of this function 
is obtained about the third year. By this time the child should be able to 
go through the night without passing urine, and should be able to control 
this function from four to six hours during the day. Either nocturnal 
or diurnal incontinence of urine after the third year is to be looked 
upon as a pathological condition. 

LITHURIA 

This condition refers to an excess of the uric acid bodies in the urine, 
and implies an excess of these same bodies in the blood and tissues. As 
noted in the above table, the urine of early infancy has a relatively low 
specific gravity, and contains a comparatively small quantity of urea. On 
the other hand, uric acid is comparatively very abundant, especially during 
the early days of life. It is probable that in the fetus, as in cold-blooded 
animals, uric acid may be one of the end-products of protein metabolism, 
but after birth this tendency to uric-acid formation rapidly diminishes. 
This may account for the uric-acid infarcts as well as the temporary 
anuria followed by the passage of a urine rich in urates, which may occur 
in the newly-born infant and may even reach a degree of pathological im- 
portance. These uric-acid infarcts, as Jacobi has taught, may be a source 
of great irritation, not only to the kidneys, but to the other urinary organs 
as well. The irritation they produce in the kidney may be manifested 
by the presence of albumin and casts in the urine, and by slight hem- 
orrhages which give a tinge of redness to the first urine passed by the 
infant. An excess of uric acid in the infant may cause a reddish staining 
of the diapers, and in older children a brick dust precipitation may occur 
when it is allowed to stand. The ureters, bladder, and urethra may be 
irritated by the uric acid in passing, and, as a result, the urine may contain 
large numbers of epithelial cells, leukocytes, red blood corpuscles, and 



562 THE UKINE 

mucus. Infrequently small renal calculi may form, and, in their passage 
through the ureters, may cause renal colic, or they may produce great 
distress by becoming impacted in the urethra. There may be a tendency 
throughout childhood to recurring attacks of acid urine in which the 
urates are in great excess ; these attacks, as a rule, occur in thin, nervous, 
irritable, quick-witted children. During the attack the general nervous 
irritability of the child is greatly exaggerated, the urine is retained as 
long as possible, and then passed with a fit of crying. The urine in some 
of these cases is so irritating that the external genitalia become swollen 
and red, and in female children a mild vulvovaginitis may result. These 
attacks last for a number of days and then pass off, the urine again re- 
turning to normal. 

INDICANURIA 

Urinary indican is almost, if not quite, entirely derived from the 
bacterial fermentation of the proteins of the food. Some observers believe 
that a small percentage of it may result from the disintegration of albumin 
in the tissues. However this may be, medical observers are for the most 
part agreed that this latter source is so unimportant that it may be con- 
sidered negligible from >a pathological standpoint. Indican in the urine 
is therefore a sign of bacterial disintegration of proteins in the intestinal 
canal, and the extent of this form of fermentation may, in most instances, 
be largely determined by the quantity of indican in the urine. 

Herter has called attention to the fact that indolaceturia (indolacetic 
acid in the urine) is also produced by the bacterial fermentation of proteins 
in the intestinal canal, and that there is a "reciprocal relation between 
the formation of indolacetic acid and indol," that is to say, when the one 
is present in large quantities the other will be found in smaller quantities. 
From this it would appear that both urinary indican and indolacetic acid 
are evidences of bacterial fermentation of proteins in the intestinal canal. 

Indican is usually absent in the urine of normal breast-fed infants, but 
is found, as a rule, in small quantities in the urine of all other individuals. 
It has pathological significance only when it occurs in excess. The quan- 
tity is generally increased in well-marked constipation and in all gastro- 
intestinal diseases. The degree of indicanuria, in many instances, marks 
the severity of the gastrointestinal intoxication. Pronounced indolace- 
turia may also be an indication of intestinal toxemia. In the routine ex- 
amination of urine, therefore, the approximate quantity of indolacetic acid 
as well as indican should be determined; an excess of these bodies in the 
urine is very commonly associated with albumin, occasional hyalin casts, 
and an excess of oxalate of lime crystals. 

HEMATURIA 

Attention is usually called to this condition by the color of the urine, 
which may be flesh-colored, smoky, brownish, or reddish; when the latter, 
it may vary from the faintest tinges to a blood-red color, depending on 



HEMOGLOBINURIA 563 

the quantity of blood in the urine. It should be remembered that in al- 
kaline urine a comparatively small quantity of blood may produce a bright 
red color. It can be differentiated from hemoglobinuria by a microscopical 
examination, which reveals the presence of red blood corpuscles in large 
numbers. Hematuria may occur under a great variety of conditions and 
be produced by disease or injury of any part of the genitourinary system. 
In newly born infants the urine passed during the first days of life may 
be tinged with blood, as a result of irritation from uric-acid crystals and 
infarcts; this form is transitory and has slight pathological significance. 
Calcium oxalate crystals, when present in excess, may also produce hema- 
turia; this may sometimes result from the eating of rhubarb, tomatoes, 
and asparagus; this form is rare and is largely a matter of idiosyncrasy; 
it is also transitory and has little pathological significance. Infantile 
scurvy is a cause of hematuria, and in severe cases of this disease red 
blood corpuscles may almost always be found in the urine, and well-marked 
hemorrhages may occur. Hematuria may be present as a symptom of sep- 
sis, hemophilia, purpura hemorrhagica, leukemia, severe forms of variola, 
malaria, scarlet fever, acute nephritis, calculus, tuberculosis, malignant 
disease, cystitis, neoplasms, and acute inflammation of the urethra (gonor- 
rhea). It may also be produced by certain drugs, such as turpentine, can- 
tharides, and large doses of chlorate of potash. 

The source of the blood in the urine cannot always be readily deter- 
mined. An examination of the external genitalia of the female will dis- 
cover whether the urine was contaminated after leaving the urethra. If 
the hemorrhage comes from the kidney, epithelial and blood casts, together 
with renal epithelium, can, as a rule, be found, and in these cases the 
quantity of albumin is out of proportion to the quantity of blood. If the 
blood comes from the bladder it commonly follows the urine and is passed 
with pain and tenesmus; if the blood precedes the urine its source is the 
urethral canal. In all cases of hematuria the concomitant symptoms are 
important in determining the source of the blood. 

Treatment. — This will depend upon the cause. Hematuria is a symp- 
tom of some constitutional disorder or local disease of the genitourin- 
ary tract, and the treatment of the causative condition is therefore the 
treatment of the hematuria. The symptom itself rarely demands special 
treatment. Fluid extract of ergot or ergotin may be given where the 
hemorrhage is excessive, and absolute rest in bed should be insisted upon. 
If the bleeding point can be reached by the injection of adrenalin solution 
into the bladder the hemorrhage may be controlled in this way. 

HEMOGLOBINURIA 

Hemoglobinuria is due to an extensive disintegration of red blood cells, 
which is followed by the appearance of blood pigment in the urine; this 
pigment, however, is commonly methemoglobin, rather than unchanged 
hemoglobin. 



564 THE TJKINE 

The diagnosis is made by the urine findings. The color of the urine 
varies from a pale red to a very dark red, depending upon the quantity 
of hemoglobin it contains. The amount of albumin present also depends 
upon the quantity of hemoglobin. Microscopic examination reveals the 
blood pigment in amorphous granules, masses, or casts, and hemoglobin 
crystals may be found, but the important diagnostic feature is the almost 
complete absence of red blood cells. Hyalin and granular casts are present, 
and renal epithelium and calcium oxalate crystals are usually found. As 
the patient convalesces from the attack, the urine gradually loses its red 
color and the above microscopic findings disappear. 

Etiology. — Hemoglobinuria is usually an expression of some severe 
toxemia. It may occur in septic conditions, scarlet fever, malaria, erysip- 
elas, and severe forms of jaundice. It may be produced by certain poisons, 
such as phenol, naphthol, arseniuretted hydrogen, toluene-diamin, and large 
doses of chlorate of potash. It may also result from the transfusion of 
blood, or the injection of a foreign serum. 

There are, however, two rather clearly defined types of hemoglobinuria 
which demand special consideration, namely: Epidemic Hemoglobinuria 
of the New-born, and Paroxysmal Hemoglobinuria. 

WINCKEL'S DISEASE 

Winckel's disease, or epidemic hemoglobinuria of the new-born, is a 
rare form of hemoglobinuria, probably due to sepsis. It makes its ap- 
pearance during the first few days of life in apparently healthy infants. 
It has been observed in epidemic form, particularly in institutions, where 
the bath water is regarded as a method of infection. An early symptom 
is cyanosis, which, together with jaundice and hemoglobinuria, forms a 
striking clinical picture. The disease is marked by profound constitutional 
symptoms, great depression, a feeble, rapid pulse, cold extremities, and is 
sometimes associated with diarrhea and vomiting. Jaundice develops 
early, and is usually intense within twenty-four hours. The urine find- 
ings are the same as above described. The disease runs a rapid and 
fatal course, commonly terminating within two or three days. Convul- 
sions and coma may be the terminal symptoms. The diagnosis of this 
form of hemoglobinuria is made by the urine findings, the age of the 
infant, and the profound constitutional symptoms above noted. 

PAROXYSMAL HEMOGLOBINURIA 

Paroxysmal hemoglobinuria is a chronic intermittent form which may 
come on in childhood and recur in paroxysms throughout the life of the 
individual. In other instances it disappears without apparent cause as 
the patient grows older. 

Etiology. — Syphilis and malaria are believed to be important predis- 
posing factors in many cases. Exposure to cold is the most common 



ACETONUKIA 565 

exciting cause of the individual attacks. They are therefore much more 
usual during the winter months. Contact with cold water is a very 
common exciting cause. The individual attacks may begin with a chill, 
which may be followed by a rise of temperature. Cyanosis, general de- 
pression, nausea, and abdominal pain may be present, and the skin may 
be slightly jaundiced. The urine findings are the same as those above 
noted. The attack is of short duration; it passes off within a few hours 
and the urine rapidly becomes normal. The frequency of these attacks 
varies greatly; in the winter they may recur at short intervals; during 
the summer they may be separated by months. 

Prognosis. — The prognosis, as far as life is concerned, is good. This 
disease may not shorten life, and some cases recover after reaching adult 
life. 

Treatment. — When due to sepsis, or the various acute infectious dis- 
eases, these causative conditions are to be treated rather than the hemo- 
globinuria. In the periodic form antisyphilitic and antimalarial treat- 
ment should be tried, and if benefit follows they should be continued. Pa- 
tients suffering from this disease should also live in a mild and equable 
climate, so as to avoid sudden chilling of the surface of the body. Cold 
baths and other exciting causes, which in the individual case are known to 
precipitate the attack, should be avoided. Martin H. Fischer believes that 
we can relieve the signs and symptoms of paroxysmal hemoglobinuria by 
increasing the salts in the diet. Sodium chlorid should be given in some 
form in every case of hemoglobinuria. 

ACETONURIA 

Oxybutyric acid is the antecedent body from which diacetic acid and 
acetone are formed. These three substances constitute the acetone group, 
and their appearance in the urine is indicative of a definite form of 
acid intoxication, which is associated with a large number of diseased 
conditions. Oxybutyric acid is formed by the disintegration of fat and 
protein molecules under unfavorable conditions of oxidation. Von Noorden 
believes that carbohydrate molecules furnish some oxygen to the fat and 
protein molecules, as they are disintegrated in the normal processes of 
body metabolism, and that the absence of carbohydrate molecules results 
in the imperfect oxidation of the disintegrating fat and protein molecules, 
and thereby causes the formation of oxybutyric acid. According to this 
view, the presence of oxybutyric acid in the blood is always due either 
to a deficient intake of carbohydrate foods or to some perversion in the 
carbohydrate metabolism, which makes it impossible for them to exercise 
their oxidizing influence on the disintegrating fat and protein molecules. 
It is my belief that this form of acid intoxication is due either to a de- 
ficient absorption of carbohydrate food or to functional or organic diseases 
of the liver, which interfere with its glycogenic function. While oxybutyric 
acid is the most important of the acetone series, it caunot be demonstrated 



566 THE UEINE 

in the urine by simple clinical tests, so that for clinical purposes the "urine 
is examined for either diacetic acid or acetone, and the presence of either 
of these bodies is an indication that this form of acid intoxication exists. 
Oxybutyric acid is the antecedent body; this is oxidized into diacetic acid 
and then into acetone, so that for clinical purposes the demonstration of 
one of the series is all that is necessary. The oxidizing processes here 
referred to are so rapid that acetone is the first of these bodies to appear 
in the urine, and the subsequent appearance of diacetic acid, and later of 
oxybutyric acid, indicates failing powers of oxidation and therefore a 
more severe form of ' autointoxication. 

This form of acid intoxication may produce deleterious results : First, 
by the direct toxic action of the acids formed; second, by removing al- 
kaline bases, such as calcium, potassium, sodium, and magnesium, which 
are necessary to the normal processes of metabolism; third, by bringing 
poisonous alkaline bases, such as ammonium, in large quantities into the 
blood (Kachford) ; fourth, by separating C0 2 from its bases, and thus 
producing carbonic acid poisoning (Herter). 

The acetone group may appear in the urine in many pathological 
conditions, and it is found much more frequently in children than in 
adults. These bodies are commonly observed in diabetes, malignant disease, 
prolonged fevers, starvation, gastrointestinal disorders, recurrent vomiting, 
other forms of severe and prolonged vomiting, nervous disorders, migraine, 
bronchopneumonia, influenza, severe malnutrition, and in poisoning from 
atropin, lead, morphin, antipyrin, and chloroform. 

Diagnosis.' — The diagnosis of this form of acid intoxication is made by 
the finding of one or more of the acetone bodies in the urine. In this 
examination it is important to remember that the reaction with a solution 
of ferrous chlorid, which is commonly used to demonstrate the presence 
of diacetic acid, may be unreliable if the patient has been taking a salicylate, 
since this drug, when excreted by the urine, gives a reaction similar to 
that of diacetic acid. If the acetone group is found in large quantities in 
the urine it is an indication of profound metabolic disturbances, one of 
the results of which is the presence of these bodies in large quantities in 
the blood. This form of acid intoxication, however, is not characterized 
by any well-defined clinical picture. By some writers it is believed that 
dyspnea, increased pulse rate, somnolence, and coma, which occur in many 
of these cases, are either directly or indirectly due to the acetone bodies. In 
all of these cases there is an increase in the urinary ammonia, and in 
some instances a decrease in the alkalescence of the blood. 

Prognosis. — The prognosis depends upon the cause. If acetonuria 
appears as a symptom of advanced diabetes or cancer, the prognosis is 
unfavorable, but even in these cases one may temporarily cause to dis- 
appear the coma and other symptoms associated with the acidosis. In 
the acetonuria, which occurs in acute malnutrition, intestinal disorders, 
fevers, and "recurrent" and other forms of severe vomiting, the prognosis 
is nearly always good. There is a form of acidosis occurring in children 



ALBUMINURIA 567 

under three years of age associated with intestinal disturbance and dyspnea 
which may terminate fatally. 

Treatment. — For the immediate relief of an attack of acidosis, from 
2 to 5 grains of calomel, combined with bicarbonate of soda, should be 
given, and should be followed by a saline laxative. Immediately afterward 
the administration of alkalies in large doses should be begun. The al- 
kaline treatment, which consists in the giving of bicarbonate, or benzoate 
of soda, should be continued for some time, in smaller doses, after the 
acetone bodies have disappeared from the urine. During convalescence, 
and for the prevention of these attacks, fresh air, preferably out-of-door 
air, is indicated, and this should be continued throughout the twent} r -four 
hours, the patient either sleeping out of doors or with wide open windows. 
Carbohydrate foods are especially indicated, and should always be given 
when the condition of the patient will permit. Exercise out of doors is 
to be recommended in all cases where t"he individual is strong enough to 
be benefited by it. Where the physical condition of the patient is such 
that outdoor exercise cannot be indulged in, general massage is to be 
recommended. A more detailed account of the treatment of acidosis is 
given in the chapter on Eecurrent Vomiting. 

ALBUMINURIA 

The presence of albumin in the urine is not always an indication of 
structural disease of the kidney. On the other hand, it is now a well- 
recognized fact that transient forms of albuminuria may occur, even 
associated with an occasional hyalin or epithelial cast in conditions other 
than true nephritis. It is necessary, therefore, that these forms of 
albuminuria should be carefully studied in order that they may not be 
confused with nephritis, and it is even more important that cases of true 
nephritis should not be mistaken for these more innocent forms of al- 
buminuria. The following forms of albuminuria may be recognized : Phy- 
siological, orthostatic, toxic, and nephritic. 

PHYSIOLOGICAL ALBUMINUEIA 

This is the transient, or intermittent, appearance of albumin in such 
quantities that it may be easily discovered by ordinary tests in the 
otherwise normal urine of a healthy child. It is comparatively unim- 
portant and deserves but passing notice. It may result from the following 
causes : excessive muscular exercise, such as bicycling, foot-racing, and 
jumping the rope; emotional excitement, such as may result from mas- 
turbation, or pseudomasturbation — this form has little or no pathological 
significance; sudden and prolonged chilling of the surface of the body, 
such as may come from a cold bath, the albumin from this cause readily 
disappears as the child reacts, and may be due either to nervous shock or 
temporary congestion of the kidney; overfeeding with albuminous food, 
this cause is sometimes associated with injuries to the metabolism from 



568 THE URINE 

the inability of the excretory organs to eliminate the excess of foreign 
albumin in the circulating media of the body. In each of the above 
instances the question may arise as to whether the term physiological can 
properly be used to designate these albuminurias, but certain it is that 
they may occur entirely apart from disease of the kidneys, and that their 
pathological importance is so slight that they can scarcely be classified 
under any other heading. The transient appearance of a faint trace of 
albumin or an occasional hyalin cast may have no pathological significance; 
in fact these findings are very common in the urine of normal children. 

The albuminuria of the new-born has been designated as physiological. 
Much attention has been given to this form by German writers, all of 
whom are agreed that it occurs in a large percentage of infants during 
the first week of life, and in a few may persist until the end of the 
second or third week without being considered a pathological process. It 
is most frequently found during the first and second days of life, but the 
percentage of infants having albuminuria rapidly diminishes after the 
third day, so that if it persists to the end of the second week it is perhaps 
wise to consider it a pathological process, unless it can be shown to belong to 
one of the other forms of physiological albuminuria above mentioned. In 
some instances the albuminuria of the new-born may be due to incomplete 
functional development of the kidney, which results in a defect in its 
filtering function; or in others it may result from the irritation of uric 
acid crystals and infarcts, which irritate the tubules of the kidney to such 
an extent that not only albumin appears but occasional hyalin and epithelial 
casts are present; or, again, it may be toxic, due to the irritation of the 
very vulnerable kidney of the newly born infant by intestinal and other 
toxins. Whatever may be the cause of these forms of albuminuria in 
the new-born, they are of no pathological importance, since the urine 
quickly clears and leaves the kidney in a normal condition. For this 
reason they can scarcely be classified as pathological. 

OKTHOSTATIC ALBUMINUEIA 

This form was first described by Pavy, under the name of Cyclic Al- 
buminuria. Since his observations, the condition has been very extensively 
studied by many observers, and Heubner proposed for it the name Or- 
thotic, or Orthostatic, Albuminuria, which term expresses the important 
fact in its etiology, that the albuminuria is postural, coming on when 
the patient is on his feet and disappearing when he assumes the re- 
cumbent posture. Pavy used the term cyclic to express practically the 
same condition; he found no albumin in the early-morning urine, while 
that passed during the day always contained albumin. This cycle which 
Pavy described, was later found to be due not to the particular time of 
day when the urine was secreted, but to the upright position of the patient 
during the day and the prone position during the night. No albuminous 
cycle occurs in these cases as long as the patient is confined to bed; 
under this condition both the night and day urines are free from albumin. 



ALBUMINURIA 569 

Etiology. — This is a pathological, not a functional or physiological, 
form of albuminuria. It is not, however, a symptom of nephritis, and, 
in the great majority of instances, does not lead to actual disease of the 
kidney. The fact should be kept in mind that all forms of pathological 
albuminurias, including the toxic and nephritic varieties, are aggravated 
by the upright position, and these forms must therefore be carefully dif- 
ferentiated from true orthostatic albuminuria. 

Heredity plays an important role in the etiology of this condition. A 
family predisposition is not infrequently found. The exact character of 
this heredity is unknown, but a gouty and neurotic inheritance is very 
commonly present. The hereditary defect, however, is perhaps a certain 
degree of functional disability on the part of the renal epithelium, which 
permits the albumin of the blood to filter through under slightly abnormal 
conditions. The fact that the upright position is the all-important factor 
in producing this form has led to the belief that some circulatory dis- 
turbance of the kidney, which is aggravated by this position, is the de- 
termining factor. Some observers have been able to demonstrate dis- 
placement of the kidney in a considerable percentage of these cases; in 
the great majority of instances, however, the kidney is in normal position. 
As this disease appears most frequently between the ages of six and four- 
teen, during the rapid growth of the child, it has been suggested that 
the instability of the abdominal viscera during this period is one of 
the causes of the disturbed circulation in the kidney. Jehle believes that 
lordosis of the lumbar vertebrae is an important etiological factor in 
many of these cases. This disease, or rather the pathological condition 
with which postural albuminuria is associated, is aggravated by anything 
that lowers the vitality of the child. Neurotic disturbances, functional 
incompetency of the liver, acute illness, and, in short, all the conditions 
which are responsible for physiological and toxic albuminuria will aggra- 
vate orthostatic albuminuria. 

Symptomatology. — While, in a few instancees, there is nothing to mark 
this condition except the urine findings, in the great majority of cases there 
are more or less well-marked constitutional symptoms. My experience is 
in accord with that of Longstein, Heubner, Still, and others, that pa- 
tients suffering from orthostatic albuminuria are physically below par; 
they are commonly nervous, anemic, have dark circles under their eyes, 
are easily exhausted, and surfer frequently from headaches and abdominal 
pain. I have observed that many of them have feeble digestive capacity, 
and suffer from fermentative disturbances in the intestinal canal; indican 
and oxalic acid are frequently found in excess in the urine, and not in- 
frequently the albuminuria is increased or diminished in proportion to the 
amount of these ingredients. 

Urine Findings. — The diagnosis can be made only by repeated careful 
examinations of urine, passed under various conditions of diet and posture. 
The urine secreted while the patient is lying down is normal, containing 
neither albumin nor casts, but the urine passed after the patient has as- 



570 THE URINE 

sumed the upright position contains albumin, sometimes in large quan- 
tities. In a patient whom I have had under observation since 1903 and who 
has now entirely recovered, albumin was often present in the early months 
of the treatment in quantities of y 2 per cent., and could at all times, when 
she was in an upright position, be easily demonstrated by the ordinary 
clinical tests. Besides the albumin in these cases, one not infrequently 
finds an occasional hyalin cast, and in rare instances an occasional 
epithelial or leukocyte cast ; cylindroids are also occasionally present ; leuko- 
cytes, squamous epithelium, and crystals of calcium oxalate, and uric acid 
are not uncommon. I have carefully studied the influence of exercise on 
these patients and have found that it does not increase the albuminuria. 
They will have more albumin in their urine when they are confined to the 
house, sitting and walking about, engaged in ordinary indoor occupations, 
than they will if made to take exercise in the open air. Walking, horse- 
back riding, golf, and other outdoor exercises diminish rather than in- 
crease the albuminuria. A milk diet will not' diminish the albuminuria; 
on the other hand, it will, if prolonged, aggravate it. These are im- 
portant points in the differential diagnosis of this condition from 
nephritis. 

Prognosis. — The present status of our knowledge of orthostatic al- 
buminuria makes it advisable that the physician render a guarded prog- 
nosis. There is no question but that some of the cases, which have been 
carefully studied by competent observers, have ultimately terminated in 
nephritis. On the other hand, there can be no question but that many 
of these cases, after years of albuminuria, permanently recover. On the 
whole, it may be said that the prognosis is favorable, and that, under 
proper care, most of these cases get well. 

Treatment. — These patients should lead an outdoor life in fresh air, 
and take a moderate amount of physical exercise. In beginning the 
treatment, it is important that the amount of exercise prescribed should 
fit the individual case, otherwise the child may be overfatigued, but as 
health and strength return no limitation should be placed upon the outdoor 
exercise other than that overfatigue should be avoided. They are never 
benefited by rest in bed; this is a measure which is only justifiable for 
the purpose of making the diagnosis. An exclusive milk diet is not only 
inadvisable, but, if prolonged, does harm. A liberal diet of milk, cereals, 
vegetables, fruits, and a moderate amount of meat and eggs should be 
prescribed. I have not been able to satisfy myself that a moderate amount 
of albuminous foods, such as meat and eggs, exerts any unfavorable in- 
fluence. The restriction therefore along this line should be that these 
albuminous foods are not taken in excess. I have further convinced my- 
self that these cases are benefited by the rigid exclusion of sweets from 
the diet. Wines and malt liquors are also contraindicated ; rich and highly 
seasoned foods are not to be recommended. In two instances I have beer 
convinced that rhubarb aggravated the albuminuria. Still advises that 
this vegetable, together with tomatoes and asparagus, be excluded from 



ACUTE NEPHEITIS 571 

the diet. I further advise the drinking of water between meals, and, above 
all, that the food of the patient should be selected to suit his individual 
digestive capacity. Intestinal fermentation is to be carefully avoided, and 
the patient's whole life is to be so directed that his general health may 
be improved and his power of resistance increased. The albuminuria 
cannot be influenced by the medical or other therapeutic measures which 
favorably influence the albuminuria of Bright's disease. 



CHAPTEE LXXIY 
ACUTE NEPHEITIS 

From a pathological standpoint the term acute nephritis comprehends a 
variety of degenerative and inflammatory changes which are produced in the 
kidney by the action of the toxins and microorganisms. The degenerative 
changes, which are confined chiefly to the epithelial cells, are for the 
most part caused by the action of toxins. The inflammatory changes, 
which include not only degeneration of epithelial structures but the in- 
filtration of the kidneys by newly formed cells, and perhaps later by 
increased growth of connective tissue, are produced by the combined ac- 
tion of bacteria and their toxins. Martin H. Fischer believes that an 
abnormal production or accumulation of acid in the kidneys, acting on their 
colloidal structures, explains the pathological findings and the resulting 
symptoms of nephritis. In the present state of our knowledge, however, 
we are not prepared to clearly differentiate either from a clinical or path- 
ological standpoint between a purely degenerative (toxic) and an inflam- 
matory (mycotic) nephritis. It is a recognized fact that, in some instances, 
both the so-called degenerative and inflammatory lesions may be pro- 
duced in the kidney by the action of bacterial and other toxins without 
the kidney itself being infected with bacteria. On the other hand, it is 
generally believed that in a large percentage of the so-called true inflam- 
matory processes of the kidney, and especially in those of a severe type, 
the kidney itself is infected with pathogenic microorganisms. While we 
recognize the existence therefore of a toxic and of a mycotic form of 
nephritis, we cannot, from a clinical standpoint, clearly differentiate these 
conditions. We know, however, that in the vast majority of instances 
the disease begins, and in a large percentage of cases remains a purely 
degenerative process produced by the irritating action on the kidney of 
toxins. We know also that in a considerable number of these cases the 
degenerative changes thus produced predispose tins organ to infection, 
and that a mycotic nephritis is added to the toxic nephritis, and when 
this occurs the gravity of the disease is greatly increased. We know also 
that a small percentage of the cases of nephritis may be classed as pri- 
marily mycotic, that is to say, the kidney is attacked by pathogenic micro- 
organisms before degenerative changes in the epithelial structures have 



572 ACUTE NEPHRITIS 

prepared the way for this infection. These cases are usually of a very 
severe type, and occur either as so-called idiopathic or primary cases, or 
during the first week of one of the acute infections, such as scarlet fever, 
diphtheria, and influenza. The terms parenchymatous, tubular, and glomer- 
ular nephritis have been used to describe various localizations of the 
ordinary toxic, or degenerative, form, while the terms acute diffused 
nephritis and acute productive nephritis have been used to describe the 
more severe inflammatory types. From a clinical standpoint, however, 
this classification is of no assistance. For these reasons we shall speak 
of the toxic and mycotic forms of acute nephritis, recognizing that they are 
frequently commingled, and, even when distinct, may be difficult of differ- 
entiation. 

TOXIC NEPHRITIS 

(Toxic Albuminuria) 

The severity of this form depends upon the virulence of the toxin, the 
length of time it acts on the kidney, and the part of the secreting structure 
attacked. These cases may, by bacterial infection, be converted into a true 
mycotic nephritis, but in the great majority of instances they run a benign 
course, the albumin and casts disappearing as the patient recovers from 
the disease, systemic or intestinal, which is producing the toxemia. 

Etiology. — This form of nephritis is commonly produced by scarlet 
fever, pneumonia, influenza, septicemia, malaria, rheumatism, cerebrospinal 
meningitis, and gastrointestinal infections. Chapin, Morse, and others have 
called special attention to the frequency of albuminuria in pneumonia and 
cerebrospinal meningitis. Chapin reported "a series of 57 cases of pul- 
monary diseases, such as severe bronchitis, pleurisy, and pneumonia, that 
gave the following results: 49 had albumin in the urine, thus noted; 
trace, 13 ; faint trace, 30 ; heavy trace, 6 ; 32 cases had casts present, either 
hyalin, granular, epithelial, or mucous/' In infancy, disease of the gastro- 
intestinal tract, as Kjelberg demonstrated, is the most common cause of 
this condition; Koplik, Morse, Chapin, and many others have also noted 
this fact. In Koplik's series of 25 cases of gastroenteritis all but 4 
had albuminuria, and in more than one-half casts were found. In Chapin' s 
86 cases of gastrointestinal disease, albumin was present in 75, and casts, 
hyalin, granular, epithelial, or mucous, were present in 37. It is a 
notable fact that in cases of gastrointestinal origin the albumin in the 
urine rises and falls with the amount of indican. This, however, does 
not necessarily mean that the indican produces the irritation of the kidney, 
but it does indicate that the products of the intestinal fermentation of 
albuminous foodstuffs, of which indican is one, are largely responsible 
for this irritation. 

Severe anemia, scurvy, icterus, and diabetes may be associated with 
albuminuria, the cause of which is perhaps toxic. Migraine, "recurrent 
vomiting/' and other autointoxications may produce albuminuria; the 



TOXIC NEPHRITIS 573 

writer, many years ago, called attention to the presence of transient al- 
buminurias occurring in connection with these toxic states. 

A few drugs and chemicals, such as turpentine, chlorate of potash, 
carbolic acid, cantharides, arsenic, and phosphorus, may, when taken in 
excess, produce a toxic nephritis. In some of these cases the irritation 
to the kidney may be so great as to produce a violent inflammation as- 
sociated with severe and dangerous constitutional symptoms. 

Symptomatology. — In the great majority of these cases the diagnosis 
must be made almost exclusively by the urine findings, since no con- 
stitutional symptoms referable to the kidney lesions are present. This is 
especially true in the toxic albuminurias which occur in infants and young 
children suffering from catarrhal diseases of the intestinal canal and 
respiratory tract, as well as in older children suffering from some form 
of autointoxication, or one of the acute infections. In these cases the con- 
stitutional symptoms of the original infection are present, and the kidney 
lesion is, as a rule, accidentally discovered by an examination of the urine. 
It must, however, be remembered that even the purely toxic forms of neph- 
ritis may occasionally be associated with kidney lesions so severe as to 
produce uremic and other constitutional symptoms. The symptom group 
occurring in these cases is similar to that detailed under the heading 
Mycotic Nephritis. 

The urine findings upon which the diagnosis is made are as follows : 
albumin, usually not a great amount; a small number of hyalin and 
epithelial casts; leukocytes, epithelial cells and mucus. The quantity of 
the urine may not be diminished, but the specific gravity is usually high, 
sometimes above 1,020. 

Diagnosis. — If the physician keeps in mind the fact that in all the 
above-named conditions mild forms of toxic (degenerative) nephritis are 
very common, and that severe forms of acute mycotic nephritis are com- 
paratively rare, he will then not easily be misled by the urine findings 
above noted. The small amount of albumin, the comparative scarcity 
of casts, and the absence of all constitutional symptoms referable to the 
kidney would justify the diagnosis of a simple toxic nephritis. 

Prognosis. — The great majority of these cases recover without ap- 
parently influencing the course of the disease with which they are asso- 
ciated. Earely, however, the toxins may be so virulent or their action 
on the kidney may be so long continued as to produce severe and dan- 
gerous forms of nephritis. In some instances, also, the toxic nephritis 
may predispose to, and later be associated with, a true mycotic nephritis. 

Treatment. — The object of all treatment is to protect the kidneys, whose 
secreting structures are beginning to break down under the elimination 
of excessive quantities of toxins. This may be accomplished in three ways, 
namely : diminishing the toxemia, eliminating the toxins through other or- 
gans than the kidney, and protecting the kidney by a non-irritating diet. 
In cases associated with gastrointestinal intoxication much can be done 
to diminish the toxemia by laxative medication. So that in every instance. 



574 ACUTE NEPHRITIS 

whatever may be the cause of the toxemia, a cathartic should be given, and 
the primary disease producing it should then receive appropriate treat- 
ment, especially with reference to diminishing and controlling, as quickly 
as possible, the general toxic condition. A most important part of the 
treatment consists in eliminating the toxins through other channels than 
the kidney. This may be done by saline cathartics, by warm baths, and 
by the administration of large quantities of alkaline water. Perhaps most 
important of all is the dietetic treatment. Where the gastrointestinal 
canal is not involved and the question of diet pertains simply to the pro- 
tection of the kidneys, the food given should be similar to that recom- 
mended in acute mycotic nephritis, milk and cereals predominating. In 
many of these cases, especially those associated with pneumonia and acute 
septic conditions, the advisability of the administration of alcohol may 
arise, the causative condition perhaps demanding alcoholic stimulation, 
which is contraindicated by the presence of albumin and casts in the 
urine. The urgency of the symptoms of the causative condition may, in 
some of these cases, demand that the dietetic treatment of the kidney irri- 
tation should be temporarily neglected. 

ACUTE MYCOTIC NEPHRITIS 

(Acute Diffuse Nephritis, Acute Productive Nephritis, Acute Bright's 
Disease, True Nephritis) 

This is an acute non-suppurative inflammation produced by bacteria 
and their toxins. It may involve any part or all of the kidney structure. 
Etiology. —It commonly occurs as a complication or a manifestation 
of the acute infectious diseases; in these conditions the primary inflam- 
mation is usually started by the irritation of bacterial toxins, which are 
eliminated in large quantities through the urine. The kidney structures 
thus inflamed are in no condition to resist the pathogenic microorganisms, 
which are also being excreted by them, and, as a result, a mycotic infection 
is added to the toxic nephritis. This secondary mycotic nephritis usually 
occurs late in the causative disease, ofttimes when the patient is believed 
to be convalescent from the acute infection. While secondary or late my- 
cotic nephritis is one of the most severe and dangerous complications of 
the acute infectious diseases, yet it is nothing like so dangerous as the 
form of acute nephritis which is produced by a primary mycotic infection 
of the kidney. Acute nephritis of this type occurs during the early acute 
symptoms of the causative infection, and becomes at once the most serious 
and dominating symptom-complex of the disease; it not infrequently as- 
sumes the acute hemorrhagic form. The so-called idiopathic or primary 
cases of acute nephritis, which occur in young children, and whose etiology 
is so obscure, represent a small percentage of this class of cases. The 
kidney is the organ primarily attacked, or the preliminary symptoms of 
the influenza, tonsillitis, "cold," or other causative factors are so slight 
as to be overlooked until a sharp and severe mycotic nephritis calls at- 



ACUTE MYCOTIC NEPHRITIS 575 

tention to the infection. The term, primary nephritis, may therefore, per- 
haps, be used in describing these cases, but the term "idiopathic" is mis- 
leading and should be discarded. 

Scarlet fever, of all the acute infections, is most commonly followed by 
acute nephritis. In this disease the skin is largely put out of function by 
the acute dermatitis, and the kidney is therefore called upon to do an 
enormous amount of work, under which it very frequently breaks down, 
and an acute toxic or mycotic nephritis results. In addition to this, the 
scarlatinal poison has a selective action on the kidney, and especially on 
its glomeruli, hence the term glomerular nephritis. Scarlatinal nephritis 
usually occurs late in the disease, and has a very gradual or insidious 
onset. It may, however, occur during the first week; this form, which is 
comparatively rare, is sudden in its onset, violent in its course, and not 
infrequently assumes the hemorrhagic type. Nephritis may also be pro- 
duced by influenza, diphtheria, enteritis, variola, rheumatism, malaria, ton- 
sillitis, typhoid fever, pneumonia, septicemia, measles, varicella, and con- 
genital syphilis. It should also be remembered, as previously noted, that 
certain drugs and chemicals, such as turpentine, chlorate of potash, car- 
bolic acid, cantharides, arsenic, and phosphorus may, in rare instances, 
produce violent inflammations of the kidneys, and that the toxic nephritis 
thus set up may terminate in a true mycotic nephritis. 

The influence of cold as a cause of nephritis has probably been greatly 
exaggerated; it may be a contributing factor. It is difficult to conceive 
how exposure to cold as an independent factor may produce nephritis, but 
it is easy to understand that it may be very important if the child be suffer- 
ing from some acute infection, that is to say, if the kidney be already 
irritated by the presence of toxins or microorganisms. 

Symptomatology. — Clinical experience has taught me to believe that 
one may determine, by the character of the onset and by the violence of 
the early symptoms, whether the disease is primarily toxic or mycotic in 
its origin. The toxic cases are more insidious and commonly present no 
constitutional symptoms; if, however, bacterial infection is added to toxic 
irritation of the kidney, pronounced and often violent constitutional symp- 
toms are gradually added to the symptom group. Cases of this character 
occur as a late complication of one of the acute infectious diseases. The 
primary mycotic cases on the other hand are comparatively violent in their 
onset, and occur with the initial symptoms of the causative disease. Under 
this heading one may include all those cases of nephritis which occur 
during the first week of the acute infectious diseases, and probably all the 
so-called "idiopathic" or primary cases in which the exciting cause is not 
apparent. These so-called primary cases have been carefully studied and 
described by Holt and others; they occur in young children, are violent 
in their onset, and run a severe and usually fatal course. 

There are three early manifestations of acute nephritis, any one of 
which may suggest its onset : First, edema, especially of the face ; second, 
certain nervous uremic manifestations, such as headache, vomiting, drow- 
38 



576 ACUTE NEPHEITIS 

siness, and disturbances of vision; third, the appearance of albumin and 
casts in the urine. The physician should therefore be ever on the lookout 
for these signs of nephritis, especially when he is treating one of the acute 
infectious diseases of childhood. 

Dropsy is one of the common symptoms of nephritis, developing early 
in the disease and usually first showing itself as a slight edema of the 
face. The eyelids may be puffy, and the whole face may gradually become 
slightly edematous, presenting a peculiar pallid color ; later the same puffy 
edematous condition of the skin may appear in the hands and over the 
lumbar region. In some instances the dropsy may spread, producing a 
general anasarca; the whole body including the legs, arms, back, abdomen, 
and scrotum, may be swollen and edematous, and the peritoneal and other 
serous cavities may contain large quantities of fluid. These cases of ex- 
tensive dropsy occur most commonly in scarlatinal nephritis, but marked 
dropsy may also be associated with nephritis due to other causes. The 
extent of the dropsy is of comparatively little value in prognosis, since 
not infrequently fatal cases of nephritis occur with little or no evidence of 
it, and, on the other hand, cases presenting most extensive dropsy not un- 
commonly terminate in complete recovery. The extent of the dropsy is 
not in proportion to the severity of the inflammation of the kidney, but 
is believed to be partly due to injury inflicted by the toxins upon the blood 
and lymph vessels. 

Idiopathic Edema. — Attention should be directed to the fact that 
edema may occur in infants quite apart from disease of the kidneys; this 
form is most frequently associated with gastroenteritis. I have observed 
this condition in children suffering from acute enteritis who were being 
fed exclusively upon beef broth, meat juice, and whiskey, and I have seen 
the edema quickly disappear when these foods were changed for a mod- 
ified milk formula. Idiopathic edema is not in any way related to nephritis, 
and is mentioned here simply to prevent mistakes in diagnosis. 

Uremia. — Headache, nausea, and vomiting are the early symptoms 
which mark the onset of this intoxication. As the toxemia increases,- the 
headache becomes more severe, the stomach more irritable, and diarrhea 
may occur. Associated with these symptoms there may be a high-tension 
pulse, muscular twitchings, drowsiness, and vertigo; later, convulsions and 
coma may occur. Coma is the most unfavorable of these symptoms; per- 
sistent vomiting associated with severe headache and disturbances of vision 
are also alarming symptoms. Since single convulsions not infrequently 
occur in patients who make a rapid and satisfactory recovery, this symp- 
tom cannot therefore be depended upon in making a prognosis. 

Urine. — The most important signs of acute nephritis are furnished 
by an examination of the urine. Albumin is usually abundant, values of 
over 1 per cent, by weight being not infrequent. The urine in such cases 
becomes dense with albumin on boiling or by the addition of cold nitric 
acid. In rare instances only a slight ring of albumin may be present. 
Casts are of more importance from the standpoint of diagnosis than is 



ACUTE MYCOTIC XEPHEITIS 577 

albumin. In all cases of acute nephritis they are found in considerable 
numbers. Hyalin, granular, blood, and epithelial casts may be distributed 
through the same field. It should, however, especially be noted that a 
small amount of albumin and a few hyalin casts, without other signs or 
symptoms, are not sufficient to make a diagnosis of nephritis; these find- 
ings, as already stated, occur in orthostatic and toxic albuminurias, un- 
associated with inflammatory changes in the kidneys. The urine in acute 
nephritis, in addition to an abundance of epithelial, granular, and blood 
casts, contains leukocytes, renal epithelium in various stages of degenera- 
tion, microorganisms, and blood corpuscles. A few red blood corpuscles, 
discovered microscopically, may have little prognostic import, but the 
presence of blood in marked quantities is an unfavorable sign and usually 
indicates a severe form of nephritis. But in cases with marked oliguria 
the hemorrhage may somewhat relieve the congested kidney. The prognos- 
tic importance, however, of blood in the urine depends upon its associa- 
tion with albumin and casts. In certain hemorrhagic diseases, such as 
scurry, the presence of blood may have little prognostic significance. In 
acute nephritis, urea, sodium chlorid. and phosphoric acid are diminished. 
The retention of urea is an especially valuable indication of defective elim- 
ination. The amount of uric acid is unchanged, and the aloxuric bases are 
increased. The urine is nearly always diminished in quantity", is concen- 
trated, reddish brown, or smoky, and has a high specific gravity, 1.030. 
Occasionally acute nephritis produces complete suppression of urine ; this is 
an ominous symptom, frequently followed by convulsions, coma and death. 

Other Symptoms. — In this connection it should be remembered that 
renal suppression may occur, lasting over twelve or even twenty-four hours, 
in young children who have no other sign of kidney disease; complete 
restoration of the kidney function quickly follows in these cases of simple 
anuria, and they are mentioned here to emphasize the fact that this 
symptom is of serious import only when it is associated with the other 
signs and symptoms of acute nephritis. 

Fever is an almost constant symptom. A rise in temperature during 
apparent convalescence from scarlet fever, diphtheria, and other acute in- 
fectious diseases should suggest nephritis and lead to an examination of the 
urine. The temperature commonly runs between 99° and 103° F. A sud- 
den rise during the course of the disease is a bad indication. 

A marked secondary anemia rapidly develops, and if the disease passes 
into the subacute or chronic stage the anemia may be an important symp- 
tom in directing attention to the patient's condition. 

Complications. — The most frequent complications are pleuritis. endo- 
carditis, pericarditis, bronchitis, pneumonia, meningitis, and edema of 
the larynx. 

Course and Termination. — Acute primary nephritis occurring in young 
children is a very fatal disease; in older children recovery is the rule. If 
these cases can be tided over the first week, a satisfactory recovery may 
be expected. In scarlatinal and other postinfectious forms recovery is 



578 ACUTE NEPHRITIS 

the rule, but death may occur. It is my experience that the great majority 
of these cases have little tendency to become chronic. The nephritis of 
childhood is a disease which has a tendency to spontaneous and com- 
plete recovery. If the patient lives, the kidney, in the vast majority of 
instances, is restored to a normal condition. The fact, however, that 
chronic nephritis may, in a small percentage of these cases, follow the 
acute form should make the physician ever careful to see that the recovery 
from acute nephritis is complete. A pseudo recovery may mislead the 
physician into withdrawing the restrictions as to diet and exercise which 
are necessary to complete recovery. The ordinary course of a case of 
acute nephritis is from three to six weeks, but thereafter the urine should 
be examined at intervals of five or six weeks to make sure that the re- 
covery is complete. 

Prophylaxis. — In the treatment of the acute infectious diseases, which 
are so commonly followed by acute nephritis, the physician should ever 
keep in mind the prophylactic treatment of this condition. This especially 
applies to scarlet fever, diphtheria, and severe febrile attacks of acute 
influenza. In all of these conditions the patient should be confined to 
bed, and his body kept at rather an even temperature. The diet should 
be such as to throw little work on the kidney and yet supply nutritional 
demands. Milk, cereals, fruit juices, and alkaline waters are especially 
indicated. When vegetables are allowed in the convalescence from these 
diseases, care should be exercised to exclude rhubarb, tomatoes, and as- 
paragus. In all the acute infections the bowels should be kept open by 
saline or other cathartics, so that the kidney may not be further irritated 
by the elimination of intestinal toxins. Warm baths may also be of service 
in promoting elimination through the skin, and thus diminishing the 
work which the kidney is called upon to do. The specific treatment of 
various diseases, such as diphtheria by antitoxin, malaria by quinin, and 
syphilis by mercury, diminishes the dangers of nephritis in these diseases. 
Throughout the treatment of all acute diseases, which may be followed by 
nephritis, the urine should be frequently examined, so that the nephritis 
may be recognized early and checked by appropriate treatment. 

Treatment. — General Treatment. — The first object to be sought is 
the reestablishment of the kidney secretion, if this function has been 
materially interfered with. To accomplish this the kidneys must be rested 
by withholding food, giving water and calling upon the bowels and skin to 
vicariously do a portion of the work of these diseased organs. Water is the 
greatest of all diuretics and is indicated at all times in all forms of ne- 
phritis. In beginning the treatment a saline cathartic should be prescribed, 
preferably the sulphate of magnesia; this should be given in suitable doses 
every three or four hours until free catharsis has been established, and dur- 
ing this time little water and no food should be taken. Sulphate of magne- 
sia, as a rule, produces less nausea, acts more quickly upon the bowels, and 
eliminates more fluid than any other cathartic. In infants and young chil- 
dren milk of magnesia, Eochelle salts, or a solution of citrate of magnesia 



ACUTE MYCOTIC NEPHBITIS 579 

may be used. After the bowels have once been moved, other saline cathartics 
may be substituted, such as sulphate of soda, phosphate of soda, or one 
of the alkaline cathartic mineral waters. Later in the disease, when the 
acute symptoms are under control, vegetable cathartics, such as cascara and 
compound licorice powder, may be used if the patient finds them more 
agreeable, but throughout the whole course of the treatment, until actual 
convalescence has been established, cathartic medication is, as a rule, 
necessary. In laying stress upon the cathartic treatment of acute neph- 
ritis it is important to call attention to the fact that, while in the beginning 
it must be very active, in the later treatment of the disease care should 
be taken not to weaken the patient or aggravate his anemia by unnecessary 
catharsis. In all severe cases, in addition to early cathartic medication, 
it is advisable to at once begin to stimulate the skin to increased action. 
This may be done by wrapping the patient in blankets wrung out of hot 
water (temperature 110° F.), and surrounding him with hot-water bottles, 
and then covering him with warm, dry blankets; this will produce copious 
perspiration. If the patient shows no marked depressing effects he should 
remain in this hot pack for ten or fifteen minutes, after which he may 
be wiped dry and covered with a warm, dry blanket. The copious sweat- 
ing which follows these measures is even of greater value in the relief 
of profound uremic symptoms than is the cathartic medication. Hot 
packs are especially valuable, however, when nausea and vomiting prevent, 
the cathartic treatment above outlined. In such cases the packs may be 
supplemented by rectal injections of from a pint to a quart of normal 
saline solution at a temperature of 105° F., or the same solution may be 
used by hypodermoclysis, 6 to 12 ounces at a dose. The following formula is 
recommended by Martin H. Fischer : "Sodium chlorid, 14 grams ; sodium 
carbonate (crystallized), 15 to 30 grams (not bicarbonate) ; water, 1 liter. 
This solution is not suitable for subcutaneous injection, but it may be given 
per rectum by the drop method at a temperature not below 105° F. In 
urgent cases it may be injected intravenously. For intravenous use it must 
be sterile. In preparing it, the sterile sodium chlorid solution should be 
made first, and as this is cooling the sodium carbonate should be added, as 
heating the latter drives off the C0 2 . After the formula has been given 
once by rectum or intravenously it is well to wait three hours before repeat- 
ing the dose. It takes a little time to get the full effect of the salt and alkali 
on the kidney. As the kidney function returns, the concentration of the 
alkali and the salt, in subsequent injections, may be progressively reduced, 
and finally a simple 0.9 per cent, sodium chlorid solution by rectum, or 
water salt and alkali by mouth will suffice." 

The above formula is the adult dose and is therefore to be diminished 
proportionately to the age of the child. At the age of five, one-fourth, and 
at ten, one-half of this dose should be given. Saline injections may be 
alternated with the hot packs at three or four-hour intervals, until the 
nausea and vomiting have sufficiently subsided to permit cathartic medica- 
tion. It should, however, be remembered that, while hot packs are life- 



580 ACUTE NEPHRITIS 

saving measures in the early treatment of these severe eases, they are also 
very depressing, and are to be discontinued as soon as the uremic symptoms 
have disappeared and the kidney secretion is again fairly well established. 
It is rarely necessary to continue the hot packs for longer than three or 
four days, and in the mild cases it may not be necessary to use them at 
all. The hot pack is also indicated and may be of great value in cases 
where there is considerable dropsy. In these cases it is to be administered 
but once in the twenty-four hours, and its effects are to be carefully 
studied ; if the patient is feeble and the pack produces great prostration, it 
may do more harm than good. Dry cupping, hot fomentations, electric 
heaters, and hot-water bottles applied to the lumbar region may not only 
relieve pain but may also increase the flow of urine by relieving congestion 
of the kidneys. 

In very severe forms of acute nephritis with sudden onset, which are 
comparatively rare, the intoxication may be so profound and the patient's 
life may be in such imminent danger that even more radical measures 
than those above outlined may be indicated to control the uremia and re- 
establish the kidney secretion. In these violent forms morphin hypoder- 
mically, 1/10 to 1/50 of a grain, depending upon the age of the child, may 
be necessary to control convulsions and vomiting; venesection should then 
be resorted to, half a pint to a pint of blood being removed. Following 
venesection, sterile normal salt solution, in quantities equal to the amount 
of blood removed, should be given by subcutaneous injection, or Fischer's 
alkaline solution above noted should be given intravenously. Fischer and 
others have reported very remarkable curative results in many severe cases 
of uremia from the use of this alkaline solution administered in the 
manner previously described. It is especially indicated in uremia and 
severe acidosis. When given intravenously it acts almost specifically in 
controlling these symptom groups. The collapse of the veins, which occurs 
in these conditions at times, makes the intravenous injection a very difficult 
operation. 

Best in bed is a necessary part of the treatment of acute nephritis and 
should be continued until albumin and casts have disappeared. If the 
heart be weak or the anemia pronounced, albumin may recur in the urine 
after the patient is allowed to sit up or be upon his feet. In such cases it 
is necessary to have the child remain in bed until these symptoms are 
controlled by appropriate treatment. In some instances, where the al- 
buminuria is prolonged, the rest-in-bed treatment may become so irksome 
to nervous children, especially in hot weather, that it may be necessary 
to place them in reclining chairs, and shift them from beds to lounges, 
as the judgment of the physician may direct. This treatment may ne- 
cessitate confinement to bed for five or six weeks; in the average case, 
however, this period is much shorter. 

Dietetic Treatment. — As above noted, food should be abstained from 
until the bowels have been acted upon and the nausea and vomiting con- 
trolled. Following this, milk should be the chief article of diet. Great 



ACUTE MYCOTIC NEPHEITIS 581 

care should be taken at all times not to overload the stomach, or to give 
food at too frequent intervals. In the early treatment, of acute cases small 
quantities of milk, 4 to 6 ounces, every five or six hours, are all that are 
necessary. After a few days the quantity of milk may be increased, but the 
intervals between the feedings should be maintained. If the child dislikes 
plain milk, then the milk may be flavored or disguised, or one of the 
proprietary milk foods substituted. The following are recommended : milk 
with cereal gruels, milk flavored with chocolate, ice cream made from clean, 
but not rich, milk, milk soups, flavored in various ways, "malt soups," 
buttermilk, malted milk, condensed milk, and other proprietary milk 
foods. In this list an easily digested milk food may be found, which the 
child can be induced to take, that will serve nutritional purposes and 
remain the basis of the child's diet throughout the disease. A little later, 
as the kidney secretion becomes better established, fruit juices, bread and 
cereals may be added to the diet. Orange juice and lemonade are espe- 
cially grateful. As convalescence approaches, potatoes, and all fresh vegeta- 
bles, except onions, rhubarb, asparagus, and tomatoes, may be added to the 
diet ; these latter are contraindicated until the child is entirely well. Small 
quantities of meat and cooked eggs may be given during early convalescence, 
but are perhaps better let alone until the urine is free from albumin. 

Fresh Air. — While the temperature of the sick room should be kept 
uniformly in the neighborhood of 70° F., the air must always be fresh. 
Fresh air and iron are the most important agents we have in combating 
the anemia which is so constant in this disease; the latter is of special 
value during convalescence. Diuretics are for the most part contraindi- 
cated. During the early stages of acute nephritis, when the kidney is 
sharply inflamed, its secreting structures cannot be stimulated to increased 
activity by such diuretics as the potash preparations or by remedies such 
as digitalis that increase the blood pressure. In the later stages of neph- 
ritis, however, when the inflammation of the kidney has largely subsided 
and the heart is weak and rapid in its action, digitalis may be of some 
value; its action, however, upon the kidney secretion as well as upon the 
heart should be carefully watched. Some alkaline water or plain water 
is, as a rule, the only diuretic needed in these cases, and after the nausea 
and vomiting have subsided the child should be urged to drink water. The 
nervous or uremic symptoms often demand symptomatic treatment in 
addition to the hydrotherapy, catharsis, and diet above recommended. 
Chloroform, morphin, chloral, and bromids may be necessary to control 
convulsions, and bromid of potash and veronal may be necessary to pro- 
duce sleep and relieve nervous irritation. I have been much impressed 
with the importance of avoiding excessive medication in these cases. Any 
medicine that irritates the stomach or interferes with the appetite will 
do more harm than good. The treatment in the vast majority of eases 
is confined to diet, hydrotherapy, catharsis, rest in bed, and fresh air. 
care at all times being taken to keep the digestive organs in good con- 
dition. 



582 OTHEE DISEASES OF THE KIDNEYS 

CHAPTER LXXV 
CHRONIC NEPHRITIS AND OTHER DISEASES OF THE KIDNEYS 

CHRONIC NEPHRITIS 

Chronic nephritis is comparatively rare in childhood, notwithstanding 
the fact that this is the period of life in which acute nephritis is most 
common. Chronic Bright' s disease in the adult is not commonly the se- 
quel of acute Bright's disease; in most instances it develops insidiously, 
and the clinical history fails to trace the beginning of the chronic disease 
to a previous attack of acute nephritis, which, through neglect, was al- 
lowed to develop into the chronic form. In the child, however, this se- 
quence is noted; but, as previously said, the tendency of acute nephritis 
in childhood is to complete recovery. We do, however, occasionally have 
the same forms of chronic nephritis in children which we have in the 
adult, and the symptomatology, pathology and treatment of these chronic 
forms are practically the same at all ages. 

Chronic diffuse non-indurative nephritis (chronic parenchymatous 
nephritis) may follow acute nephritis produced by scarlet fever, influenza, 
syphilis, and, less rarely, other causes. This form occupies an intermediary 
position between acute nephritis and chronic indurative nephritis; all 
three may be stages of the same pathological process. In acute and chronic 
diffuse nephritis the secreting structures are especially involved in the in- 
flammation. In the indurative form the interstitial tissue is also involved. 
Amyloid disease is a degenerative process, which may rarely be engrafted 
upon the chronic nephritis of childhood. Marked amyloid degeneration 
in the child, as in the adult, is usually associated with tuberculosis, syphilis, 
suppurative processes, chronic malaria, rickets, and diseases which produce 
cachexia. Amyloid changes are not confined to the kidneys; other organs, 
such as the liver, spleen, intestines and suprarenal glands, are also involved. 

Symptomatology. — The symptoms of chronic nephritis in childhood are 
the same as the symptoms of chronic nephritis in the adult, except that 
the disease is not, as a rule, so insidious. When albumin and casts are dis- 
covered for the first time in the urine, it is important to determine whether 
the condition is a chronic one, and, if so, of how long standing. If the 
disease has lasted for a year it has passed beyond the acute stage, and it 
is not only unwise, but positively injurious, to subject a patient of this 
kind to the dietetic and "rest-in-bed" treatment recommended for acute 
nephritis; the differential diagnosis between acute and chronic nephritis 
is, therefore, most important. Chronic nephritis differs from acute neph- 
ritis in that it is an afebrile disease, and the casts which are found in 
the urine, while they are largely granular and epithelial, contain large 
numbers of fat granules, both in and out of the epithelial cells, and free 
fat drops are commonly seen. Eed blood cells, if present at all, are 



CYSTOPYELITIS 583 

scarce; albuminuric retinitis is more common; eccentric hypertrophy of 
the heart with dilatation usually exists. Anemia is more marked, and 
the whole appearance of the disease is that of a chronic rather than an 
acute process. Confusion may arise in the differential diagnosis of chronic 
from acute nephritis when the patient is seen for the first time with an 
acute exacerbation of a chronic Bright' s disease. In such instances the 
urine has the high specific gravity, the dark color, the excessive quantities 
of albumin, and the microscopic findings, including red blood cells and 
blood casts, seen in acute nephritis. 

Treatment.- — The treatment of all acute exacerbations of a chronic 
nephritis should be the same as that of acute nephritis ; the milk diet and 
rest-in-bed treatment are necessary in these cases until the acute symp- 
toms are controlled. The treatment of chronic nephritis is, however, very 
different from that of the acute form. These patients should be out of bed, 
and, if the climate is suitable, in the open air. If the patient can take ad- 
vantage of climatic treatment he should live the year around in dry, 
warm, bracing and equable climates; to do this he must necessarily travel 
with the seasons. Muscular exercise to the point of physical fatigue is 
to be carefully avoided. 

The diet is also very different from that of acute nephritis. While 
milk, buttermilk and all the milk foods recommended in the acute disease 
should form the basis of the diet, yet these patients live much longer and 
are capable of accomplishing much more if they are given a very general 
diet. Fruits, cereals, vegetables and albumin should form part of their 
diet. Albumin is not only permissible, but is really a very valuable food 
in chronic nephritis. It may be given in the form of cooked (never raw) 
eggs, fish, chicken, mutton, and even beef in moderate quantity to suit the 
individual case. Albumin in some form should be given once a day, but 
care should be taken that the patient does not overeat; that is to say, that 
the number of calories in the food taken should not exceed that required 
by a normal individual of the same weight. These patients should avoid 
alcohol, radishes, asparagus, onions, tomatoes, rhubarb, and all pickled 
and smoked foods. Water is never contraindicated, even when the urine 
is scant and the dropsy is marked. In the great majority of cases the kidney- 
secretion is comparatively free, and dropsy is either not present at all, or 
but slightly marked. In these cases ordinary water, or certain alkaline and 
lithia waters, such as Poland and Waukesha, should be given in large quan- 
tities. 

Edebohls' operation of splitting the capsule of the kidney, while not 
curative, prolongs the life and adds greatly to the comfort of the patient. 

CYSTOPYELITIS 

This condition is a purulent infection of the urinary bladder and 
pelvis of the kidney; it is peculiar to infants and young children. By 
American and English writers it is commonly described under the term 



584 OTHEK DISEASES OF THE KIDNEYS 

Pyelitis ; by the Germans it is spoken of as Cystitis. It is probable that 
in the vast majority of cases the bladder is primarily infected and the 
disease spreads secondarily to the pelvis of the kidney, in some instances 
involving the kidney structures (pyelonephritis). In a small minority 
of cases, however, it is known that the infection begins in the kidney and 
subsequently affects the bladder, so that perhaps the term cystopyelitis 
most accurately describes this condition. 

Etiology. — Age and sex are important predisposing factors. It may oc- 
cur in the first weeks of life, but is comparatively rare before the third 
month. From this time to the eighteenth month it is common, and there- 
after diminishes in frequency, up to the sixth year of life. After this 
period cystitis in the child is very similar in its etiology and course to 
cystitis in the adult. The predisposition of females is shown by the fact 
that only about 10 per cent, of these cases occur in males. Enteritis 
is the most common predisposing cause. It may also follow influenza, 
scarlet fever, diphtheria, typhoid fever, gonorrhea and other forms of 
vaginitis and urethritis. Stone in the kidney or bladder, congenital mal- 
formations of the urinary organs, foreign bodies, irritation of the urinary 
organs by toxins, hyperemia of these organs from cold or other causes, and 
retention of urine, are spoken of by various writers as predisposing 
causes. 

Exciting Causes. — The colon bacillus is the common exciting cause. 
This fact was pointed out by Escherich in 1894; he reported 60 cases, in 
58 of which this bacillus was found, either in pure or mixed culture. These 
findings have been confirmed by all subsequent observers. It may there- 
fore be definitely stated that the ordinary cystopyelitis of infancy is due 
to the bacillus coli communis. Pfaundler further confirmed this etiologi- 
cal relationship by demonstrating an agglutination reaction of these bacilli 
with the blood serum of a patient sick with this disease. Other micro- 
organisms, however, may produce a purulent cystopyelitis. Among these 
the following may be mentioned: bacillus proteus vulgaris, bacillus lactis 
aerogenes, staphylococci, streptococci, gonococci, and typhoid, tubercle, 
pyocyaneus, and diphtheria bacilli. 

Infection in the vast majority of cases occurs from below upward 
through the urethral canal. In these cases cystitis is probably the primary, 
and pyelitis the secondary, lesion; this is especially true of infection by 
the colon bacillus. Infection may occasionally occur through the blood 
stream, primarily affecting the kidney. The infecting microorganisms may 
also migrate directly through intervening tissues from the intestinal canal 
to the urinary organs. The two latter modes of infection, however, are 
comparatively rare, so that from a clinical standpoint it is well to recognize 
the fact, not only that the vast majority of these cases are caused by colon 
bacilli, but that these infecting organisms commonly find an entrance 
through the urethral canal to the urinary bladder and later to the kidney. 
With these facts in mind one can understand why this disease occurs so 
frequently in young female infants whose urethral canals are exposed to 



CYSTOPYELITIS 585 

contamination from fecal discharges, and also why this disease is so com- 
monly the sequel of enteritis. 

Symptomatology. — Genebal Symptoms. — Local symptoms, such as 
pain and tenderness over the bladder and frequent and painful urination, 
may lead to the discovery of this condition through an examination of the 
urine. In the majority of cases local symptoms on the part of the genito- 
urinary organs are either not present at all, or are so slight as to be over- 
looked. In this fact lies the difficulty of diagnosis, or rather, one should 
say, it explains why this condition is so commonly overlooked. The diag- 
nosis of these cases is simple enough where the symptoms are such as to 
cause the physician to make a urine examination, but since routine exam- 
inations of the urine of infants are not commonly made in private practice 
he depends upon the constitutional, rather than the local, symptoms to 
direct his attention to the location of this infection. An unexplained fever 
is the most notable and constant of these constitutional symptoms. It is 
commonly associated with more or less gastrointestinal disturbance and 
frequently with the following symptoms : restlessness, nervous irritability, 
anorexia, nausea, abdominal colic, pain and tenderness over the bladder, 
and a more or less marked and progressive pallor. If physicians would 
examine the urine of every infant suffering from a fever the cause of 
which was not clearly defined, but few of these cases would be overlooked. 

The fever in cystopyelitis is usually continuous, showing marked re- 
missions. It may, however, be intermittent or septic in character, rising 
to 104° or 105 °F., and falling, within twenty-four hours, below normal. 
In acute cases the fever is important, both from the standpoint of diagnosis 
and prognosis; the bad cases are marked by high and irregular fever and 
a cessation of the febrile process usually means approaching convalescence. 
In mild cases the febrile reaction may be slight. Chronic cases may con- 
tinue for an indefinite period with little or no elevation of temperature. 

In very severe cases the clinical 'picture may be even more obscured 
and attention may be directed away from the urinary tract by symptoms 
resembling typhoid fever, pneumonia, severe intestinal intoxication or 
meningitis. That this disease does occasionally present the appearance 
of the above-named infections is a fact which should be kept in mind. 
Mistakes in diagnosis can be prevented only by systematic urine examina- 
tions in all infectious processes characterized by pronounced constitutional 
symptoms. 

In chronic cases this disease may be complicated by the coexistence of 
the symptom-complex elsewhere described as recurrent vomiting. I have 
seen cases of this kind, such as are reported by Porter and Fleischner. 

A tender tumor in the kidney region may sometimes be found by 
palpation. This, as a rule, indicates a pyelonephritis or a pyelitis, in 
which the pus is distending the pelvis of the kidney. In these cases the 
fever curve is high and intermittent; that is to say, markedly septic in 
character, and the other constitutional symptoms are much aggravated. 
Convulsions and other uremic symptoms may intervene in the fatal cases. 



586 OTHER DISEASES OF THE KIDNEYS 

Urine. — The diagnosis is made by the urine findings. Pus cells in 
great numbers, as well as renal (caudate) and bladder (squamous) epithe- 
lium, are found. A small quantity of albumin and occasional casts, hyalin 
and granular, are present in many of the cases. The specific microorgan- 
isms causing the disease may be discovered if the proper technique is used. 

The urine in the majority of these cases is acid in reaction ; this is true 
in all cases produced by the colon bacillus, and in the extremely rare cases 
produced by the tubercle bacillus. It is alkaline in reaction when the dis- 
ease is produced by septic cocci. In the more severe cases where the kidney 
structure is involved the filtered urine contains much albumin, and a 
microscopic examination shows many epithelial, granular and blood casts; 
blood corpuscles may also be found. 

In chronic cases an X-ray picture may be of value in determining the 
size of the kidney, and the presence or absence of a kidney stone. 

Course and Termination. — A small percentage terminate fatally as a 
result of kidney involvement or general sepsis. In about 95 per cent, the 
prognosis, so far as life is concerned, is favorable, and the tendency, as a 
rule, is to spontaneous and complete recovery. A considerable number of 
the cases which ultimately recover pass from the acute to the subacute 
form of this disease and continue for many months or even years. 

Prognosis. — Thf prognosis depends largely upon the character of the 
initial infection. The colon cases are the most favorable; these most com- 
monly terminate in recovery in from two to eight weeks. Cases in which 
septic cocci predominate are more prolonged, more severe and more dan- 
gerous. If diphtheria bacilli are found, the disease is even more serious, 
and the finding of tubercle bacilli usually justifies an unfavorable prog- 
nosis. It should be remembered that simple cases, due primarily to colon 
bacilli, may by neglect or maltreatment be converted into severe and dan-* 
gerous cases of mixed infection, in which the septic cocci play the most 
important role. 

Relapses may occur in cases that have apparently recovered; Abt re- 
ports two relapses in twenty cases ; one of these had three attacks. 

Prophylaxis. — The prophylactic treatment consists in keeping the geni- 
tal organs of the infant clean, by changing the diaper and carefully wash- 
ing and drying the external genitalia as soon after 'the discharge of fecal 
matter as possible, the object being to prevent the colon bacillus from en- 
tering the urethral canal. Vaginitis and urethritis in the infant and 
young child should receive prompt and careful attention. 

Treatment. — Some of the milder cases require little treatment other 
than quiet, cleanliness, and careful attention to diet. Enteritis when 
present should receive attention. Alkaline waters are valuable diuretics. 
Citrate of potash, recommended by Holt, in 3- to 5-grain doses three times 
a day, is of value. One tablespoonful of a saturated solution of sodium 
phosphate in every bottle or glass of milk I have found of great service in 
chronic cases associated with constipation. Bicarbonate of soda may also 
be given in the food. 



TUMORS OF THE KIDNEY 587 

Urotropin is perhaps our most valuable remedy during the acute stage. 
It may be given three times a day, in from one- to three-grain doses, de- 
pending upon the age of the child; it is an effective urinary antiseptic, 
which materially assists in shortening the course of the disease. In some 
instances, as Abt has noted, this drug may cause "renal and vesicle irri- 
tation"; it is then contraindicated. Salol is a valuable remedy, especially 
in young infants ; it may be given three times a day, in two- to five-grain 
doses, according to the age of the child, without disturbing the gastro- 
intestinal tract ; it acts as a mild urinary antiseptic. Guaiacol, which is 
excreted largely through the urine, acts like urotropin and salol as a uri- 
nary antiseptic ; it is especially valuable in very young infants. It may be 
given in the form of the carbonate in two- to four-grain doses three times 
a day, or in liquid form it may perhaps better be administered by inunc- 
tion. For this purpose one drachm of liquid guaiacol is combined with 
one ounce of anhydrous lanolin, and one drachm of this ointment is thor- 
oughly rubbed into the skin of the abdomen or axillary regions once a day 
(see chapter on General Therapeutics). 

Both autogenous and stock bacillus coli vaccines have been used very 
successfully in these cases. This vaccine treatment should, therefore, be 
tried in cases that fail to respond in a reasonable time to the above-named 
measures. 

Irrigation of the bladder is, as a rule, inadvisable and unnecessary; 
in refractory cases, however, it may be resorted to. For this purpose a 
weak solution of nitrate of silver, 1-2,000, or a saturated solution of 
boracic acid are recommended. High temperatures may be treated by ice- 
bags to the head and sponging with cold water. In those rare cases where 
the X-ray locates a stone or other foreign body in the urinary passages 
surgical intervention is necessary. 

TUMORS OF THE KIDNEY 

Sarcoma is by far the most common of kidney tumors. Osier says 
that nearly all large, solid, abdominal tumors in children are sarcomatous. 
Birch-Hirschfeld describes these malignant tumors of the kidney under 
the term embryonal adenosarcomata, and believes that primary carcino- 
mata are relatively rare. From a clinical standpoint further classification 
than this is unnecessary, since all malignant tumors of the kidney have 
practically the same etiology, symptomatology, prognosis and treatment. 
Usually only one kidney is involved, the left more frequently than the 
right. 

Etiology. — Little or nothing is known of the causative factors. Chronic 
irritations, from traumatic causes, are said to precede the formation of 
tumors in many cases. They have their origin in embryonal tissues, and, 
as they develop, the kidney structure is gradually destroyed by compres- 
sion; they push out from the region of the kidney downward and inward, 
until in time they may fill the entire abdominal cavity. In their early 



588 OTHER DISEASES OF THE KIDNEYS 

development the kidney alone may be involved, but late in the disease 
metastasis may occur, involving the liver, lymph nodes, and other organs; 
the bladder, however, is rarely affected. These tumors may be present in 
the new-born; the great majority of them occur during the first five years; 
they are very rare after the tenth year. 

Symptomatology. — The tumor is the characteristic symptom; in most 
instances it develops insidiously. Attention may be called to this condition 
by the appearance of blood in the urine, but, as a rule, enlargement of the 
abdomen is the first symptom noticed, and a physical examination then 
reveals the tumor. In its early stages it may be unilateral, and may be 
felt protruding from the region of the kidney downward and inward into 
the abdominal cavity; later it may become so large as to produce great 
abdominal distention so symmetrical that a physical examination may 
with difficulty discover which kidney is involved. Small tumors, discov- 
ered early, are firm and solid ; large ones are soft and doughy to the touch. 
These, when they have reached a size where they can be easily palpated, 




Fig. 86. — Sarcoma of the Kidney: Infant Four Months Old. (J. F. Bell.) 

grow rapidly, and should not be> mistaken for enlargement of the liver or 
spleen. Both of these organs, when enlarged, produce a board-like smooth 
tumor, the edge of which can be sharply outlined by palpation and per- 
cussion; this is not true of malignant growths. The location of the dis- 
tended colon running along and above these tumors may be made out 
and is of importance from the standpoint of differentiation, particularly 
from enlargements of the spleen and liver. 

Hematuria is a common and early symptom which is said to occur 
more frequently in carcinoma. The blood may be so abundant as to be 
made out by the naked eye; in most instances, however, the microscope 
reveals the hemorrhage. Pain is a common but not a characteristic symp- 
tom; it may be severe, but is usually dull, producing discomfort and irri- 
tability. As the tumor becomes very large pressure symptoms appear, and 
displacements of the abdominal viscera are common. In the later stages 
cachexia, emaciation and loss of strength are pronounced symptoms. As- 
cites and swelling of adjacent lymph nodes are also present, When both 
kidneys are involved, uremic symptoms may mark the closing stages of 
the disease. 



CYSTIC DEGENERATION OF THE KIDNEY 589 

Treatment. — The complete removal of these tumors by surgical meas- 
ures is advised in all cases where cachexia and profound nutritional dis- 
turbances do not exist; about 70 or 75 per cent, survive the operation; 
6 or 7 per cent, of these ultimately recover, and those that do not recover 
are, for the time being, made more comfortable and life is prolonged. If 
the operation is made while the tumor is yet small and confined to the 
kidney, the prognosis is much more favorable. The symptomatic medical 
treatment of these cases consists in making the patient as comfortable as 
possible by relieving pain and nervous irritability by the judicious use of 
phenacetin, aspirin, or some preparation of opium, such as paregoric, 
codein or morphin. 

HYDRONEPHROSIS 

Hydronephrosis in children is a comparatively rare condition. It is com- 
monly congenital, but there is an acquired form, which may occur late in 
childhood. 

Etiology. — It is due to obstruction in some part of the urinary canal, 
commonly the ureters ; in rare instances the stenosis may occur lower down 
in the bladder or urethra. The blocking of the urinary canal may be caused 
by calculi, inflammatory adhesions, malformations, twisting of the ureters 
and tumors. These mechanical obstructions impede or prevent the flow 
of urine through the urinary canal, and this results in an accumulation of 
fluid in the pelvis of the kidney, which gradually produces a fluctuating 
tumor. The pressure of this fluid may destroy the kidney substance. 

Symptomatology. — The characteristic symptom is a fluctuating tumor 
which may be large enough to extend downward and inward from the region 
of the kidney well into the abdominal cavity. Aspiration of this tumor 
obtains an albuminous fluid, containing urates, urea, and epithelium. 
Hydronephrosis is usually unilateral; when bilateral, it early terminates 
fatally. 

Treatment. — When hydronephrosis is unilateral, and the urine dis- 
charged shows that the other kidney is normal, radical surgical measures 
for the removal of the diseased kidney are justifiable. Such cases are 
very rare and are more commonly found in the acquired form in older 
children. 



CYSTIC DEGENERATION OF THE KIDNEY 

Cystic degeneration of the kidney is congenital and almost always 
bilateral. By the development of cysts in the kidney structure the func- 
tional efficiency of these organs is destroyed, and the infant dies from 
uremia. This condition is fortunately rare, and is of little interest excepl 
from the standpoint of diagnosis. Congenital cystic kidneys are palpable 
at birth. 



590 OTHEE DISEASES OF THE KIDNEYS 



TUBERCULOSIS OF THE KIDNEY 

Tuberculosis of the kidney is almost always a secondary condition. 
The diagnosis is made by the symptoms and signs of tuberculosis elsewhere 
in the body and by the finding of tubercle bacilli in the urine. The urines 
of these cases usually contain red blood cells, albumin and pus. Pro- 
gressive anemia, loss of weight and strength, an irregular temperature 
curve, and other symptoms of tuberculosis are usually present. 



PERINEPHRITIS 

Perinephritis is an inflammation of the tissue in which the kidney is 
imbedded; it is a rare condition, commonly terminating in abscess. The 
disease is secondary to tuberculosis, or pyogenic infections in the kidney 
or elsewhere in the body. Traumatism is classed as an important etiological 
factor. It is important to keep in mind that perinephritic abscesses, al- 
though rare, may occur, and that the pus may burrow downward, forming 
a fluctuating mass beneath the liver or the spleen. In these cases there 
is tenderness on pressure in the lumbar region, and, on deep pressure, 
bimanual examination may reveal a soft tumor. Chills, fever, and the 
symptoms of septicopyemia are present. The treatment of this condition 
is surgical. 

DISLOCATION OF THE KIDNEY 

Both the kidney and suprarenal glands are relatively large in infancy; 
at birth the suprarenals are nearly one-third the size of the kidneys. The 
kidney itself is 1/100 of the body weight, while in the adult it is about 
1/230, so that at birth it is relatively more than twice as large as in the 
adult. The lobulated form of the fetal kidney persists for a short time 
after birth. Notwithstanding the relatively large, size of the kidney at 
this period of life, it cannot be palpated, nor can it be readily located by 
percussion. A kidney, therefore, that can be palpated at or shortly after 
birth may, as a rule, be classed as a congenital dislocation. There are two 
types of this deformity : the floating kidney, which is rare in inf ancy, and 
dystopia or downward displacement of the kidney, which is still more rare. 
In the latter condition the kidney is not more movable than normal, but is 
found well down in the abdomen. This displaced kidney is commonly lobu- 
lated and its ureter is short. 



GONORRHEAL VULVOVAGINITIS 591 

CHAPTER LXXVI 
DISEASES OF THE GENITAL ORGANS 

GONORRHEAL VULVOVAGINITIS 

Gonorrheal vulvovaginitis in infants and young children differs from 
the gonorrhea of the older child and adult, in that it is rarely a venereal 
disease. It is caused by the accidental inoculation of the vulvovaginal 
canal with the gonococcus of Neisser. It is confined exclusively to female 
infants and young female children. The corresponding condition, gonor- 
rheal urethritis, is very rare in the male infant and child. It occurs in 
extensive and at times almost uncontrollable epidemics in institutions for 
infants and young children. In this tendency to spread in epidemic form 
without sexual contact, it is wholly unlike gonorrhea in the adult; it also 
manifests itself in a less virulent form, and has fewer complications. In 
recent years it has become much more prevalent, so that at the present 
time it can usually be discovered in all large institutions caring for female 
children. Holt finds that 5 per cent, of cases applying for admission to 
the Babies' Hospital in New York have this disease. It is also not uncom- 
monly seen in private practice. Holt graphically describes the difficulties 
of combating it in hospital practice, and notes the fact that 273 cases 
occurred within five years in the Babies' Hospital, in spite of "the united 
efforts of the physicians and superintendents in quarantine and disinfec- 
tion." 

Etiology. — Institutional epidemics can usually be traced to the admis- 
sion of a case of this disease into a ward containing other children. It 
is then rapidly spread by means of bathtubs, diapers, underclothing, bed- 
linen, thermometers, and other things that may carry the contagion from 
the infected child to the genital tracts of other children. Holt has espe- 
cially dwelt upon the fact that the nurses' hands may frequently carry this 
contagion. It is the testimony of all physicians who have studied the spread 
of these epidemics in very young children that in some indirect way the 
genital tracts are readily inoculated with the contagion when it exists in 
the ward, and also that it is almost impossible to prevent the spread of 
this disease if the infected child is allowed to remain in the ward, or to 
associate in any way with well children. It may occur in the new-born ; 
in such cases the vaginal canal of the infant is inoculated during birth 
by the vaginal discharges of the mother. The great majority ef cases occur 
between the third and fifth year of life. It will thus be seen that the 
vaginal canal of the young child is remarkably susceptible to this con- 
tagion, and it is believed by many writers that scarlet fever (Alice Ham- 
ilton), measles, and possibly other acute infections render them oven more 
susceptible. The writer in 1906 reported an epidemic occurring in a 
diphtheria ward, but he attributed the spread of the disease to overcrowd- 
39 



592 DISEASES OF THE GENITAL OKGANS 

ing rather than to an increased predisposition produced by diphtheria. 
Gonorrheal vaginitis occurring in older children, from seven to twelve 
years of age, may be due to sexual contact, or it may result from the child 
sleeping in the same bed with an adult who has this disease. These cases, 
both in their etiology and clinical course, more closely resemble the disease 
as it occurs in the adult. 

Symptomatology. — In the great majority of cases the disease is discov- 
ered accidentally, there being no subjective symptoms to call attention to 
disease of the genital tract. The vaginal discharge is the all-important 
sign. It may be so slight as to be almost unrecognizable, or so copious as 
to stain the napkins, underclothing or bed-linen. It commonly has the 
appearance of mucopus; in some cases it may be glairy and tenacious; in 
others it may be thin, yellowish, greenish, and tinged with blood. In 
aggravated cases small ulcerations may occur. The experience of recent 
years has demonstrated that the vast majority, perhaps 95 per cent, of 
severe cases of vaginitis occurring in young children is due to the gono- 
coccus, or at least one may say that in such cases a microorganism, which 
cannot be differentiated from the gonococcus of Neisser, is found. In 
practically all of these cases, however, the gonococcus is associated with 
other microorganisms, such as are found in cases of so-called simple vagi- 
nitis; among these may be mentioned streptococci, staphylococci, colon 
bacilli and pseudodiphtheritic bacilli. The ultimate diagnosis in these 
cases is made by the demonstration of gonococci in the vaginal discharges. 
This demonstration is commonly made by finding the gonococci within the 
pus cells. The failure of these cocci to decolorize under Gram's method of 
staining is considered characteristic. In long-standing cases, as Heimann 
and others have pointed out, gonococci may be demonstrated only by cul- 
ture methods. 

In mild cases there may be very little swelling of the labia and vagina, 
but in others these parts may be red, swollen and much irritated. In 
some instances the child complains of discomfort, and painful urination 
may indicate that the urethra is involved. The inflammation may be 
limited to the vagina in the early stages, but in the great majority of cases 
it is probable, as Koplik insists, that the cervix uteri is also inflamed, and 
this is especially true of children over six years of age. In infants and 
very young children the disease is probably more frequently confined to 
the vagina. In children over seven years of age the inflammation is usu- 
ally more severe, the secretion more copious, the parts more swollen and 
the Fallopian tubes, as well as the uterus, more likely to be involved; these 
are the cases which may possibly produce sterility in after life. Suppura- 
tion of the inguinal glands may rarely occur in older children. This 
condition is, for the most part, an afebrile disease, but in some cases during 
the most acute stage the temperature rises to 101 °F. In long-continued 
cases nutrition may suffer; this is probably due to the confinement, and 
lack of fresh air and exercise, which the treatment entails. 

Complications. — Complications are comparatively rare. I treated a 



GONORRHEAL VULVOVAGINITIS 593 

series of 40 cases in the Cincinnati Hospital without a single complica- 
tion. During this time, however, three cases of gonorrheal conjunctivitis 
were admitted; in all of them there was a coexistent vaginitis. The litera- 
ture of this subject shows that the following complications may occur: 
conjunctivitis, arthritis, endo- and pericarditis, stomatitis, peritonitis, cys- 
titis and proctitis; of these, conjunctivitis is by far the most common. 
Holt reports 26 cases of acute gonococcus arthritis, 19 of which were in 
male infants, and only three presented at any time any other evidences 
of gonorrheal infection; two were associated with vaginitis. 

Prognosis. — Nearly all of these cases finally get well ; very few of them 
terminate fatally. The course of this disease is, as a rule, tedious; it 
usually continues for from one to four months, and may last for years; 
relapses are common in cases apparently cured. Occasionally an eye may 
be lost, and sterility may possibly result in older children. 

Prophylaxis. — The prophylactic measures necessary to prevent the 
spread of this disease in institutions which care for female children may 
be outlined as follows : All female children applying for admission should 
be carefully examined, and if there be the slightest evidence of vulvo- 
vaginal irritation or catarrh they should be kept carefully isolated until 
repeated microscopical examinations of their vaginal secretions have demon- 
strated the presence or absence of the gonococcus. The fact that the vast 
majority of these cases of vaginal catarrh sooner or later show the pres- 
ence of the gonococcus has caused most clinicians, who have had experi- 
ence with this disease in institutions, to exclude all cases of this kind from 
children's wards, even though the gonococcus cannot be demonstrated. 
This latter plan is perhaps the safest rule to follow, since the non-gonor- 
rheal cases are also infectious. During an epidemic it is wise to set apart 
a ward where all infected cases may be at once isolated from those not 
having the disease. Infected children should wear diapers holding pads 
of gauze covering the genitalia, and these pads should be changed fre- 
quently, and destroyed by burning. All clothing, linen, etc., should be 
soaked in bichlorid solution before they are sent to the wash. Nurses 
should be carefully instructed as to the danger of carrying the infection 
on their hands and thus producing conjunctivitis, or reinoculating the 
vaginal canals of convalescent children. To avoid these dangers the nurse 
should thoroughly cleanse and disinfect her hands after giving the treat- 
ment or handling infected clothing. The ward bathtub should not be used 
for bathing purposes, and the toilets should be carefully cleansed after 
each individual use. Each patient should be provided with a separate 
catheter and other instruments used in the treatment, and following the 
treatment these should be carefully cleansed and placed in separate bottles 
containing carbolic acid solution and labeled with the child's name. 

Treatment. — The most important part of the treatment is the thorough 
douching twice a day of the vaginal canal with large quantities of some 
non-irritating alkaline antiseptic. In my experience the degree of success 
will depend not alone upon the care which is exercised in avoiding injury 



594 DISEASES OF THE GENITAL OEGANS 

to the inflamed parts, but also on the character of the instrument used for 
carrying the antiseptic solution into the vagina. The small female catheter, 
which is almost universally recommended, is not at all suited for this 
purpose, since the blunt end of the catheter pushes the discharge ahead of 
it to a point high up in the vagina, quite out of reach of the antiseptic 
solution which passes through the eye of the catheter. After a long and 
unsuccessful use of this and other instruments, I conceived the idea of 
having this same small-sized female catheter perforated at the end and an 
additional hole made in the opposite side, so that there would be three 
openings through which the antiseptic fluid might escape in irrigating the 
vagina. The hole in the end of the catheter is of the greatest importance, 
as it allows thorough irrigation of the cervix of the uterus and the vault 
of the vagina. It is also important that the catheter used should be small 
enough to insert with ease into the vagina, and the nurse should be in- 
structed to exercise great care in its use, so that the slightest trauma to 
the parts may be prevented. In 1906 I recorded my success with this 
method of treatment, and since that time I have been more and more im- 
pressed with the fact that attention to details, as above outlined, is abso- 
lutely necessary to success. 

In my experience the best irrigating solution is normal salt solution 
containing 5 to 10 per cent, of boracic acid; of this two or three quarts 
are to be used night and morning, to be followed by the injection through 
the same catheter of three ounces of a 1 per cent, solution of nitrate of 
silver. As the inflammation subsides the strength of the nitrate of silver 
solution may be increased to 2 or 3 per cent. This is to be continued 
for ten days after the discharge has ceased and gonococci are no longer 
found. The patient should then be transferred to another ward and kept 
under observation for ten days or two weeks without treatment. If at the 
end of that time there is no return of the vaginal discharge and no gono- 
cocci are found, the patient may be finally discharged. 

Other irrigating solutions, such as a weak solution of permanganate 
of potash, or a saturated solution of boracic acid, have been widely recom- 
mended in these cases, and 10 to 40 per cent, solutions of argyrol have 
also been successfully used, following the antiseptic douche. My experi- 
ence with the vaginal douche above outlined has been very large, and I 
have never seen bad results follow its use, and am, therefore, inclined to 
think its value is so great, and the risk of infecting the cavity of the uterus 
so slight, that it should unhesitatingly be used in all cases. 

Vaccine Treatment. — Investigations have shown that these cases may 
be benefited by vaccine treatment, but it is advisable in each case to deter- 
mine the opsonic index of the individual before the treatment is begun, 
in order that the value of the vaccine injections may be correctly deter- 
mined. Alice Hamilton made a careful study of this treatment and came 
to the following conclusion : "Better results are obtained by the use of 
strains which have been grown for a long period on artificial media than 
by the use of freshly isolated strains, and there appears to be no advan- 



TTRETHBITIS IN MALE CHILDREN 595 

tage in using the patient's own organism. While the inoculation treat- 
ment does not produce a marked effect during the first weeks in acute 
cases, it seems to shorten the later stages; in chronic cases its effects are 
more evident than' in acute. It is desirable, though not absolutely essen- 
tial, to control the inoculation by the patient's opsonic index." 

SIMPLE VULVOVAGINITIS 

Koplik states that this condition is not infrequent, and that the local 
symptoms are very similar to the gonorrheal form of this disease. The 
differential diagnosis between the two is made by the presence or absence 
of the gonococcus in the vaginal discharges. The great majority of other 
writers have found simple vaginitis in children under six years of age to 
be a comparatively rare disease. Only about 5 per cent, of the well-marked 
cases of vaginitis belong to this class; in 95 per cent, the gonococcus is 
found some time or other in the course of the disease. In children over 
six years of age, however, a simple, mild, vaginal catarrh is not so infre- 
quent. 

Etiology. — It is believed, especially in older children, that general mal- 
nutrition and the acute infections may predispose to this disease; tuber- 
culosis, anemia, measles, influenza, and scarlet fever may be etiological 
factors. Among the exciting causes the following have been named: 
dirt, foreign bodies, pin worms, scabies, masturbation, and traumas from 
any cause. The inflammation is maintained by streptococci, staphylococci, 
colon bacilli, pseudodiphtheritic bacilli, and perhaps other microorganisms. 
One or more of these bacteria may be demonstrated in the vaginal dis- 
charge. The diagnosis of simple vaginitis depends not alone upon the 
presence of a mucopurulent discharge, but upon the failure to demonstrate 
gonococci in this discharge. The local symptoms differ from those of true 
gonococcus vaginitis only in the severity of the inflammatory process. The 
labia and vagina are red and swollen and covered with a mucous or puru- 
lent secretion, and the catarrhal process may, in severe cases, involve the 
cervix. The urethra may also be involved, producing painful micturition. 

Course and Treatment. — These cases yield more readily to treatment 
than those of gonococcus vaginitis; they may commonly be brought under 
control within two or three weeks. The local treatment is the same as that 
outlined for gonococcus vaginitis. If tuberculosis, anemia, or other forms 
of malnutrition be present, these conditions should receive appropriate 
treatment, and ofttimes the cure of the local condition waits upon the cure 
of the underlvin£ constitutional trouble. 



URETHRITIS IN MALE CHILDREN 

Simple urethritis resulting from uncieanliness and infection may occur 
in young children. The meatus is swollen and inflamed, and on pressure 
a few drops of pus may exude from the urethra. Urination is more or loss 



596 DISEASES OF THE GENITAL OKGANS 

painful. The condition yields readily to treatment. The external parts 
are to be kept clean, dusted with an antiseptic powder. Salol and bi- 
carbonate of potash should be given internally. 

Gonorrheal urethritis occurring in older boys has the same etiology and 
treatment as in the adult. 

ADHERENT PREPUCE 

Adherent prepuce is due to an agglutination of the epithelial layers 
of the glands and prepuce; it is present in nearly every male infant. The 
treatment consists in forcibly retracting the prepuce, separating the ad- 
hesions, removing the retained smegma and anointing the parts with vase- 
lin. This procedure is to be repeated at intervals of a few days, until there 
is no longer any tendency to agglutination of the mucous membranes. 
From time to time throughout infancy and early childhood this process 
may have to be repeated. 

PHIMOSIS 

Phimosis may result from a long and thickened prepuce, from a con- 
genital narrowness of the preputial orifice and from inflammation of the 
parts (balanitis). 

Symptomatology. — Phimosis is very common; in many cases the child 
suffers no inconvenience and symptoms calling attention to the condition 
may be absent; in others the parts may be inflamed and irritated and the 
passage of urine causes pain and increased irritation. Where the opening 
is very small the urine may have difficulty in escaping, and balloon- 
ing of the prepuce may occur with urination; in these cases the re- 
tention and decomposition of the urine may add to the irritation and pro- 
duce a balanitis. Phimosis not infrequently induces priapism, and in- 
fantile masturbation may result. It is also one of the most common reflex 
factors of such neurotic disturbances as night terrors, incontinence of 
urine, general nervous irritability, hysteria and sleeplessness. 

Treatment. — In mild cases the preputial orifice should be dilated, the 
foreskin retracted, the agglutinated surfaces of the mucous membranes 
separated, the smegma carefully removed and the parts anointed with vase- 
lin or some other ointment. This process is to be repeated from time to 
time until the preputial orifice is fully dilated and the mucous membranes 
are no longer in a condition of irritation that will result in their agglutina- 
tion. In cases where this procedure is not followed by success, or in those 
cases in which the prepuce is very long and the preputial orifice is very 
narrow, circumcision should be resorted to. Circumcision is very much to 
be preferred to the dilation treatment if the latter has to be continued 
over a long period of time. 

PARAPHIMOSIS 

Paraphimosis is a complication which sometimes occurs in phimosis 
when the foreskin, retracted over the glands, becomes strangulated in this 



HYPOSPADIAS 597 

position. It is characterized by marked edema of the strangulated prepuce 
and congestion of the glands. In some cases this strangulation may be 
overcome by pressure upon the glands in such a manner as to force it 
through the constriction. If this manipulation fails the constriction must 
be relieved by a surgical operation and circumcision mav be performed at 
the same time. 

HYDROCELE 

Hydrocele is an accumulation of fluid in the peritoneal sac surround- 
ing the testicle and epididymis. In the congenital variety there is a direct 
communication between the hydrocele sac and the peritoneal cavity, and 
the fluid may be pressed upward and made to disappear in the abdominal 
cavity. In true hydrocele of the tunica vaginalis the upper portion of 
the hydrocele sac is closed, and the tumor cannot be made to disappear by 
pressure: in this condition a well-marked oval tumor is present, either on 
one or both sides of the scrotum. Fluctuation may be made out, and the 
illumination test may differentiate the testicle from the more translucent 
hydrocele fluid. In hydrocele of the cord the tumor extends upward and 
is elongated; an encysted hydrocele of the cord occurs when the hydrocele 
fluid is held in this position between two constrictions. 

Treatment. — Hydrocele in infancy usually disappears without treat- 
ment. If, however, the condition persists, the fluid may be drawn off by 
puncturing the sac; should the tumor recur from time to time, the with- 
drawal of the fluid may be followed by the injection of 1 or 2 drops of 
tincture of iodin, in the hope that the irritation following this procedure 
will obliterate the sac. If the congenital form persists, a truss may be worn 
to facilitate adhesions in the canal which communicates with the abdom- 
inal cavity. 

UNDESCENDED TESTICLE 

The testicles are usually found in the scrotum at or shortly after birth. 
In rare instances, however, the testicle does not descend ; it may remain in 
the inguinal canal or in the abdominal cavity. The diagnosis is made by 
an examination of the parts which results in finding the scrotum empty 
on one side, rarely on both, and a small tumor, the size of the infantile 
testicle, in the inguinal canal. Undescended testicle, as a rule, requires 
no treatment unless it be so caught in the inguinal canal as to be pressed 
upon and give rise to pain and irritation. Under these conditions surgical 
treatment may be necessary to remove the testicle from its position in 
the canal into the abdominal cavity, or, if possible, to its normal position 
in the scrotum. 

HYPOSPADIAS 

Hypospadias is a congenital deformity of the male genital organs, in 
which the urethra does not extend to its normal orifice in the head of the 



598 DISEASES OF THE GENITAL OKGANS 

penis. It opens on the under surface of this organ at some point between 
the base of the scrotum and the end of the penis. Beyond the opening the 
urethra may be represented by an open fissure extending some distance 
along the inferior surface of the penis. In severe cases the opening may 
occur in the perineal region, producing a fissure which extends beneath 
the scrotum, and because of the rudimentary condition of the penis and 
undescended testicle, which are not infrequently associated with this con- 
dition, it may be mistaken for hermaphrodism. The incontinence of urine 
which occurs in these cases is a source of great annoyance and results in 
more or less irritation of the parts. In the milder cases surgical inter- 
vention may partially overcome this deformity. 

EPISPADIAS 

Epispadias is a very rare malformation in which the urethra opens 
on the upper surface of the penis and beyond this opening a furrow may 
extend to the glans. 

ENURESIS 

Enuresis in children is a symptom usually neurotic in origin. It is not, 
as a rule, associated with a muscular incompetency of the sphincter 
vesicae. The cases of incontinence of urine due to malformations and 
paralysis are not included under this heading. Enuresis, like the 
other neuroses of childhood, commonly rests upon a tripod of etio- 
logical factors, viz. : 1, irritable and unstable nerve centers due to 
age and heredity; 2, bad blood and consequent malnutrition; 3, re- 
flex irritation. In many cases these three factors coexist. It is not 
wise, without a most careful examination of the individual case, to 
assume that any one of these factors is the sole cause of this condition. 
A rational inquiry into the etiology of a case of enuresis must seek for 
the presence or absence of each of these factors, and must determine their 
relative importance in producing this syndrome. 

The detrusor muscles of the bladder, which by their contraction expel 
its contents, and the sphincter muscle, which by its contraction prevents 
the escape of urine from the bladder, are enervated by sensory and motor 
nerves from the lumbar cord. The bladder is emptied, or its contents re- 
tained, according to the paths through which the nervous impulse from 
the lumbar center is carried. Another most important fact to bear in 
mind is that while the urination center in the spinal cord may be excited 
to discharge its impulses from reflex excitation, it is, to a large extent, 
in normal children, under the inhibitory control of higher centers, includ- 
ing the voluntary centers in the brain cortex. This inhibitory function 
of the higher centers exercises a marked control over the discharge of 
nerve force to the bladder from the urination center in the cord; the act 
of urination is, for this reason, largely under the control of inhibitory 



ENUEESIS 599 

centers and partly under control of the will. We will to urinate or not 
to urinate, and the message passes down to the center in the lumbar cord 
where, by the mechanism just described, the bladder is emptied or its con- 
tents retained. 

Etiology. — The etiological factors of enuresis may also be divided with 
reference to the manner of their action, into three classes: First, those 
that act upon the higher centers, diminishing their inhibitory control over 
the urination center in the lumbar cord; second, those that act directly on 
this center in the cord, making it more irritable and unstable, and in that 
way increasing its reflex excitability; third, those that act by reflex irri- 
tation indirectly on the spinal centers, touching off the nervous impulses 
which produce urination. 

Predisposing Causes. — Age is a most important predisposing factor. 
In early life the nerve centers are more excitable and reflex phenomena 
of all kinds are greatly exaggerated, and in addition to this there is a 
functional immaturity of the centers inhibiting reflex acts. In early in- 
fancy inhibition is so feebly developed that we have a normal incontinence 
of urine. As the infant grows older the mechanism inhibiting reflex acts, 
becomes better developed, so that by training it may acquire fair control 
of the bladder during waking hours, about the seventh or eighth month of 
life; but, during sleep, incontinence of urine may continue, even in the 
normal child, through the second year; after the third year it should be 
considered pathological. The delayed development of the mechanism 
which controls urination, in the great majority of instances, does not per- 
sist beyond the seventh year, but enuresis from various causes may continue 
into adult life. 

Heredity. — A neurotic inheritance is an important predisposing cause 
of enuresis. It may manifest itself as a family tendency, and children 
with enuresis not infrequently have other nervous symptoms. 

Chronic malnutritions due to tuberculosis, improper feeding, unhy- 
gienic surroundings, enteritis, rheumatism, malaria and syphilis are po- 
tent factors in producing enuresis. Influenza and other acute infections, 
by interfering with the child's general nutrition, may prolong or cause 
a recurrence of enuresis. Children of gouty parents who have inherited a 
marked uric acid diathesis, not infrequently suffer from this condition. As 
Williams has noted, a thyroid insufficiency may also produce enuresis. 

Exciting Causes. — Reflex irritation in some form is such an impor- 
tant exciting cause of enuresis that it can be found in about half of the 
cases. The reflexes which are most closely associated with enuresis have 
their origin, as a rule, in genital, vesicle and rectal irritations. The most 
important reflex causes are phimosis, preputial adhesions, contraction of, 
or granulations in, the meatus, vaginitis, urethritis, hyperacidity of the 
urine, an excess of oxalates and urates in the urine, bacteriuria (com- 
monly due to colon bacilli), cystitis, calculi, contracted and intolerant 
bladder, thread worms, fissure and eczema of the anus, and rectal polypi. 
Reflex irritations having their origin in diseases of distant organs such as 



600 



DISEASES OF THE GENITAL ORGANS 



the throat, nose, eye and intestinal canal, may be associated with enuresis, 
and the removal of these distant reflex causes of irritation may exercise 
a favorable influence on the course of the disease. 

Habit. — It should be remembered that whatever may have been the 
important etiological factors of enuresis, the condition may continue even 
after they are apparently removed. The continuance of the enuresis in 
these cases may in part be due to the spinal irritability which still per- 
sists, but it may be dne to the habit which has been formed of emptying 
the bladder when it cor tains but a small quantity of urine; this habit is 
apparently engrafted upon the nervous mechanism which controls urina- 
tion. 

Ruhrah offers the following table as a summary of the causes of noc- 
turnal enuresis: 

Physiological — Taking too much fluid. 



Eliminative 



Urine . 



Genitourinary organs, 



Nervous system 



General , 



Due to faulty metabolism. 
Eating too much salt, etc. 
Due to drugs. 

Hyperacidity. 

Alkalinity. 

Bacteriuria. 



Urethritis. 

Cystitis. 

Pyelitis. 



Inflammations . . . 

Malformations. 

Calculi. 

Tumors or polypi. 

Hypertrophy. 

Hypertonia or irritability of bladder. 
Weakness of sphincter. 

Balanitis. 

Vulvovaginitis. 
Reflex J Anal fissure. 

Eectal polypi. 

Intestinal parasites. 
Malformation of spinal cord. 
General irritability. 

Diabetes mellitus. 

Diabetes insipidus. 

Bachitis. 

Thyroid insufficiency. 

Enlarged adenoids and tonsils. 



EJSriTBESIS 601 

Symptomatology. — Enuresis, in about 55 per cent, of the cases, occurs 
only at night. About 40 per cent, are both nocturnal and diurnal, and 
about 5 per cent, are diurnal only. Incontinence of urine may occur once 
or several times during the night, or in milder cases days or weeks may 
intervene. Nocturnal incontinence occurs most commonly soon after the 
child goes to bed; at this time sleep is most profound. Enuresis, not 
being due to paralysis, or lack of development of sphincter muscles, does 
not have as one of its symptoms dribbling of the urine; on the other hand, 
the contraction of the bladder empties this organ as thoroughly as under 
normal conditions. 

The urine should be examined with reference to increased acidity and 
the presence of bacteria, crystals, and other causes of bladder irritation; 
infection with the colon bacillus is a not uncommon cause. 

Prognosis. — The prognosis as to ultimate recovery in nearly all cases 
is good. The great majority can be cured by careful systematic treatment 
within a period of two to six months. Even untreated cases, as a rule, 
recover by the seventh year of life. A small percentage resist all methods 
of treatment, and may persist even into adult life. 

Treatment. — General Treatment. — In the treatment of no other 
neurosis of childhood is it of more importance to remove every possible 
cause of reflex irritation. It is a waste of time to begin medical or other 
treatment until a most careful search for reflex factors has been made. 
Phimosis should be relieved by circumcision, or by stretching the prepuce 
and carefully uncovering the glans; an adherent or contracted prepuce 
must not be allowed to persist. Genital, vesicle and rectal irritations, 
from the causes previously named, should be removed by appropriate medi- 
cal or surgical treatment, and sources of reflex irritation in the throat, 
nose and eye should receive attention. Digestive disturbances of all kinds 
should be removed by proper medication. 

The diet in all cases is important, even though the intestinal functions 
be normal. It is a good, general rule to exclude sweets, pastry, coffee, tea, 
beef juice, beef tea, and alcohol. The amount of nitrogenous food stuffs 
must be regulated to suit the individual case. Well-nourished children 
of gouty diathesis, having a tendency to acid urine and high specific 
gravity, should be given meat and eggs sparingly, but with children suf- 
fering from tuberculosis and other forms of chronic malnutrition these 
foods are indicated. In this latter class of cases tonics, such as cod-liver 
oil, iron and arsenic, may be of value, and. fresh air, night and day. is 
important. 

The child should be protected from excitement and nervous strain; 
should not be permitted to go to school; should be put to bed early and 
should have the whole routine of his daily life carefully regulated. He 
should neither be punished nor threatened with punishment for wetting the 
bed. He should, however, be made to understand the importance of over- 
coming this habit by retaining his urine for as long a time as possible 
during the day. If the child can be taught to accustom the bladder to hold 



602 DISEASES OF THE GENITAL OKGANS 

considerable quantities of urine for some hours during the day, the habit 
on the part of the bladder of discharging urine when only partly filled may 
not be carried over into the night. 

In nocturnal incontinence of urine the child should take as little fluid 
as possible after four o'clock in the afternoon, and should be awakened to 
empty his bladder about an hour and a half after going to bed. The foot 
of the bed should be raised so that the child's shoulders will be lower than 
his hips, and he should, if possible, be prevented from sleeping on his back ; 
incontinence of urine does not occur so readily when the child sleeps upon 
his side or stomach. A cold douche to the spine, once a day, may act as a 
tonic to the irritable spinal cord and assist in the cure of certain trouble- 
some cases of enuresis; it may not, however, be well borne in nervous, 
malnourished children. 

Medical Treatment. — Belladonna is the one drug which all writers 
recommend, and it is, without doubt, of great value. It should be remem- 
bered that belladonna may be given in comparatively large doses to chil- 
dren, and that to get results the dose must be gradually increased until 
the enuresis is controlled, or until pronounced physiological symptoms, 
such as dilatation of the pupils, dryness of the throat, or redness of the 
skin, are produced. In this event the drug is to be discontinued and subse- 
quently administered in smaller doses. For a child of six years one may 
begin with a dose of three minims of the tincture three times a day; 
after three or four days the quantity may be increased one drop a day, until 
physiological symptoms are produced, or until the child is taking twenty- 
five or thirty drops in twenty-four hours. Holt says : "A convenient 
method of administration is to use a solution of atropin, 1 grain to §ii of 
water, of which one drop (1/1,000 of a grain) may be given for each year 
of the child's age. For nocturnal incontinence this dose should at first 
be given at four and ten p. m. ; after a few days at four, seven and ten p. m. 
Usually this may be gradually increased until double the quantity is given. 
A child of five years would then be taking ten drops (1/100 of a grain) 
at each of the hours mentioned. I have rarely found it advisable to go 
above these doses." 

If the symptoms are benefited or controlled by the belladonna treatment 
this drug should be continued in smaller doses (one-half the size of the 
maximum dose) for months, or until the incontinence of urine has been 
controlled for a period of two or three weeks, and thereafter one dose 
should be given at bedtime for a period of four or five weeks. The bella- 
donna treatment creates a tolerance on the part of the bladder which en- 
ables it to hold larger quantities of urine, and thereby materially assists 
in overcoming the habit of frequent urination. 

Alkalies are indispensable in the treatment of cases in which there is 
a marked uric acid diathesis, and in which there is an excess of urates 
and acids in the urine. In these cases the belladonna should be given with 
benzoate of soda, or bicarbonate of potash or soda, and this prescription 
may be made more palatable by the addition of peppermint water com- 



DEFINITION AND SYMPTOMATOLOGY 603 

bined with some simple elixir. For a child of six years, five grains of 
either of these alkalies may be given after meals. It is better to prescribe 
the alkali, and the belladonna, or atropin, in separate bottles, so that the 
dose of the belladonna may be increased without incrpasing the alkali. In 
children having a periodic tendency to a return of acid urine these al- 
kalies should be given over a long period of time. 

Constipation, which is frequently present, may be overcome by a daily 
dose of phosphate, or sulphate of soda, given in carbonate waters to cover 
its taste. 

In nervous, hysterical children, not of the acid urine type, bromid of 
potash given at bedtime may be combined with the belladonna treatment. 
It is, as a rule, not advisable to continue the bromid treatment for more 
than a week or ten days. 

Strychnin has been very widely recommended in the treatment of 
troublesome cases of enuresis. It is perhaps of most value in those cases 
in which the incontinence occurs during the day as well as during the 
night. It should be combined with the belladonna treatment. It is per- 
haps contraindicated in nocturnal incontinence occurring in children hav- 
ing an exaggerated reflex irritability. 

Urotropin in y 2 - to 1-grain doses three times a day is of decided value 
in those cases having a highly acid urine produced by a colon infection 
of the urinary tract. 

Williams has noted the fact that a small group of cases respond readily 
to the judicious use of thyroid therapy. He recommends that undersized 
children having a subnormal temperature, a poor peripheral circulation 
and presenting a high arched palate, adenoids and enlarged tonsils and 
who do not respond to other methods of treatment should be given y 2 grain 
of dried thyroid twice a day. In suitable cases a marked improvement 
occurs within a week and a cure rapidly follows. Williams further notes 
that with the disappearance of the enuresis the child rapidly gains in 
weight. 



CHAPTEK LXXVII 

PSEUDOMASTUKBATION IN INFANTS 1 

Definition and Symptomatology. — Pseudomasturbation is a syndrome 
in infancy and early childhood which has been described in medical litera- 
ture under the titles, "Thigh Friction" and "Infantile Masturbation." It 
is commonly accomplished with the child lying on its back; the thighs 
are flexed, crossed and pressed tightly together, closely embracing the ex- 
ternal genitalia; in this position the infant makes a wriggling, or up-and- 
down body movement, and rubs its thighs together. In oilier instances 

1 This chapter is taken, with slight modifications, from the author's paper on 
this subject in the Archives of Pediatrics, August, 1907. 



604 



PSEUDOMASTURBATION IN INFANTS 



GENITAL 
TUBERCLE 



- \N 



the genitalia are rubbed with the hands or feet, or against some piece of 
furniture or other foreign object. These movements are apparently at- 
tended by a pleasurable excitement; the face is flushed and there is a 
marked increase in the general nervous tension. Following this act, which 
continues for a few minutes only, there is general relaxation, accompanied 
by mild perspiration, quiet contentment, and, in some instances, sleep. 
These attacks may occur many times in twenty-four hours, or days or 
weeks may intervene between them. 

Etiology. — Age is the most important etiological factor. In the fe- 
male the urinary bladder, the rectum and the external genitalia, includ- 
ing the clitoris, the labia major a and labia minora, are all derived from 
the same membrane, viz., the mesoderm of the allantois and cloaca. In 
the male analogous structures are derived from the same source. 

The internal genital organs, including ovaries, uterus and vagina in 
the female, and analogous structures in the male, are derived from, the 

Miillerian ducts and the geni- 
tal ridges; and although 
these are of mesodermic 
origin, they are developed 
quite independently of that 
portion of the mesoderm 
which is being transformed 
into the urinary bladder, the 
rectum, and the external geni- 
talia. The Miillerian ducts 
and genital ridges make their 
appearance later than the al- 
lantois and are united with it. 
The accompanying draw- 
ings illustrate the common 
origin of the urinary bladder, 
the rectum and the external 
genitalia, and also show the entirely different origin of the internal genital 
organs. The union between these groups of organs takes place about the 
fifth week of embryonic life, but there is a marked difference throughout 
embryonic life in their anatomical and physiological development. 

The bladder, rectum, and external genitalia are rapidly developed, so 
that, at birth, the rectum and bladder have reached a fair state of physio- 
logical competency; and the external genitalia, being developed from the 
same structures, have been carried along in their evolution until they also 
have reached a considerable degree of development; the clitoris itself is 
almost as large and as sensitive as it becomes later in life. This, how- 
ever, is not true of the internal organs of generation, which at birth are 
in a very incomplete state of anatomical and physiological development; 
and the rudimentary condition of these organs, according to Otto Kiistner, 1 
1 "Lehrbuch der Gynakologie, " 1904. 




y\U_ANTOlS 

I 

<gfr? URETER 

-~ k '^<''.^£ Duct of mOu.eh 
Hi no CUT 



NOTOCHORO 



NCVfeAl CANAL 



-Embryo of 10 mm. (About Five Weeks). 

Ectodermic Tissue ; Entodermic Tissue; 

.... Mesodermic Tubes ; Shading = Mesodermic Tis- 
sue. (H. L. Woodward.) 



ETIOLOGY 



605 



continues in the girl until she is ten years of age. 1 He says: "From 
birth until the beginning of puberty there is no real change in the genital 
tract of the girl. The uterus and vagina during this period undergo no 
development." 

The close anatomical and physiological relationship existing between 
the bladder, rectum and external genitalia of the infant is still further 
shown in the nerve supply of these organs, which is practically derived 
from the same source, viz., the third, fourth and fifth sacral nerves and 
the mesenteric, sacral, and hypogastric plexuses of the sympathetic. These 
facts explain why the external genital organs of the infant, a few months 
after birth, are capable of responding to reflex excitation originating in 
any of the above-named parts, and why this excitation finds expression in 
producing a miniature syndrome so like true masturbation that one must 
conclude that this portion of the infantile genital system, which is later 
in life to come in 
closer touch with the 
fully developed inter- 
nal sexual organs, 
must even at this ear- 
ly date in its develop- 
ment have impressed 
upon it the peculiar 
physiological function, 
which makes it re- 
spond to reflex excita- 
tion by mimicking the 
sexual orgasm. 

Physiological f unc- 



an us r~ ••'■*►" 







m 



INTBSTlNe 

.. ' : . ' ? 
^^5sS£^ /^WOLF/AN OwCT 



/ ; v 



=-_.***■ 



NOTOtHOftO 
NEURAU CAlNAk 

Fig. 88. — Embryo of 25 mm. (About Nine Weeks.) 



tions go through vari- 
ous stages of evolution 
in the embryo, so that 
at birth most of them 
are developed to a state 
of physiological competency; this is not true, however, of the functions of 
the internal sexual and reproductive organs, which, as previously stated, are 
at this time both anatomically and physiologically in a very low state of de- 
velopment; so low, in fact, that they are as yet not endowed with physio- 
logical functions. In the infant, therefore, while we may have produced 
by reflex excitation of the external genitalia a syndrome which mimics 
the syndrome of true masturbation, we cannot have the fully developed 
orgasm, or a syndrome that equals true masturbation in the profundity of 
its sensations, or in the injurious effects it produces on the general nerv- 
ous system. 

In the child, after ten years of age, the internal sexual organs undergo 
rapid anatomical and physiological development, and (hiring those years 
of development the intense feelings which accompany the sexual act may 



606 



PSEUDOMASTITBBATION IN INFANTS 




ANUS 







ANT OF 

OUFIAN DwCf 



be evoked by reflex excitation. This is the beginning of true masturba- 
tion. I do not mean to say, however, that true masturbation may not oc- 
cur in certain children before they are ten years of age. Heredity and 
long-continued reflex excitation may cause a premature development of 
the internal sexual organs, carrying with this development a sexual pre- 
cocity, which may make true masturbation a possibility in some children 
at a much earlier age. Pseudomasturbation, however, occurs as early as 
the fourth month, and the average age of onset of this neurosis, in my 
cases, is sixteen months. 

Sex. — The majority of cases of true masturbation occur in male chil- 
dren, while of 60 cases of pseudomasturbation 55 occurred in female and 
5 in male infants. 

Habit. — The habit which is formed by the practice of pseudomasturba- 
tion becomes after a time one of its most potent etiological factors. No 

such sensations can be 
produced by exciting 
any other nervous 
mechanism in the 
body. In the first in- 
stance the excitation 
may be purely acci- 
dental, or it may have 
been caused by some 
local irritation ; but 
after a time the fre- 
quent excitation of 
this nervous mechan- 
ism makes it more ir- 
ritable and more eas- 
ily excited, so that 
very slight reflex ex- 
citation is capable of 
producing a paroxysm of pseudomasturbation. 

In the older child, environment may act as an etiological factor by 
throwing children together, offering the opportunity for imitation. It 
may also act by surrounding the child with an atmosphere of immorality 
and vice, which offers no restraining influence upon the development of 
this habit. In the infant, environment may predispose by producing bad 
hygienic surroundings, which may mean uncleanliness and lack of care 
of the genital organs, with increased local excitation, or it may mean mal- 
nutrition and other causes of general nervous irritability. The fact should 
also be noted that unscrupulous nurses sometimes teach infants the habit 
of pseudomasturbation as a means of quieting their fretfulness. 

In fully three-fourths of the cases there is a distinct neurotic in- 
heritance; in infants suffering from hereditary neuroses the reflex causes 
of pseudomasturbation may be very slight ; so slight, in fact, as to escape 



Fig. 89. — Child at Birth. 



TKEATMENT 607 

observation. A gouty inheritance may also predispose to this condition by 
producing in infants a tendency to periodic attacks of acid urine. I have 
had under observation a number of such cases where there was a return 
of the pseudomasturbation with every return of the attacks of acid urine, 
from which these infants suffered. 

Malnutrition in infants suffering from pseudomasturbation influences 
very much the severity and frequency of the attacks. An attack of en- 
teritis, influenza, or any other acute disease, which causes a rapid de- 
terioration in general health, will produce a return of the habit, which can 
again be relieved only by complete convalescence from the intercurrent 
disease. 

Direct Causes. — Irritation of the nervous mechanism which controls 
the sexual organs is the all-important exciting factor in the development 
of pseudomasturbation in infancy. The site of this irritation in the vast 
majority of cases is in the genitourinary organs, the rectum or the lower 
portion of the large intestine. 

Prognosis. — This is good. I am convinced that pseudomasturbation 
occurring in infants under two years of age will almost always get well 
under proper treatment. The tendency in this disease is to spontaneous 
recovery, and the average length of time required to bring about this re- 
sult is about nineteen months. The disease is a habit neurosis, and time, 
with a normal development of the nervous system which tends to stability 
and greater inhibitory control, is the most important factor in the cure 
of the worst cases. There is almost no connection between pseudomas- 
turbation in infancy and true masturbation in later life. It is possible, 
however, that a badly neglected case of pseudomasturbation occurring in a 
strongly neurotic infant may continue until it becomes one of true mas- 
turbation in the child. 

There is, I believe, no relationship between pseudomasturbation and 
epilepsy. The two conditions may coexist, and one can understand that 
the neurotic conditions which produce or underlie epilepsy may predispose 
to pseudomasturbation, but surely pseudomasturbation as here differentiated 
from true masturbation cannot be classed among the causes of epilepsy. 

Treatment. — In the treatment of pseudomasturbation, as in the treat- 
ment of all habit neuroses, it is imperative that the habit be interrupted 
as soon as possible. The importance of this cannot be overestimated. The 
habit, whatever may have been its original exciting causes, has been en- 
grafted upon the nervous system, and an interruption breaks into and 
helps destroy the habit, and in this way makes for the permanent cure of 
the affection. The accomplishment of this purpose, in some cases, is a 
matter of great difficulty. In the vast majority of cases, however, it is a 
comparatively easy matter. 

As this act is performed, as a rule, while the infant is lying down, 

and commonly when it awakens from sleep, and when the parts are more 

or less irritated by the soiled diaper, it is imperative that a careful nurse, 

by constant watching, shall be present to forcibly prevent the act by tak- 

40 



608 PSEUDOMASTUKBATION IN INFANTS 

ing the child up, changing the diaper, cleansing the parts, and dusting 
them with a soothing powder. The watchfulness of the nurse should con- 
tinue throughout the waking hours of the child, so as to keep the parts 
always clean, dry, and free from irritating discharges. The child should 
be kept in a sitting posture as much of the time as possible, and even when 
taken for an outing should, if old enough, be carried about in a go-cart 
in preference to the ordinary baby carriage; the object of this is to keep 
the child in the position which least tempts it to practice the act, and the 
nurse should be directed to forcibly interfere at all times to prevent its 
accomplishment. 

In children over two years of age mild punishment is sometimes very 
effective, and the child, when old enough, should be given to understand 
that it will be rewarded if it abstains from the habit. Moral suasion 
should be practiced with older children. It is evident that the above treat- 
ment can only successfully be carried out by an ever-watchful, patient, 
judicious nurse. 

In the more severe cases forcible restraint during sleep may be neces- 
sary, as the infant cannot be watched constantly during the long hours of 
the night, and it may on waking practice this habit. Forcible restraint 
may be practiced in many ways. No special device is suitable to all cases. 
But if the physician is sufficiently impressed with the necessity for this 
method of treatment, the particular mechanical device by which the end 
is to be accomplished may be left to his ingenuity. If the infant sleeps in 
pajamas the heels of this garment may be fastened by safety pins to the 
mattress in such a manner as to hold the legs apart, and prevent the 
flexion of the thighs; at the same time the child's body is prevented from 
slipping down in the bed by a ribbon stretched from the back of the 
pajamas to the head of the bed. In younger children a large diaper may 
be folded, as suggested by Kerley, so as to prevent the thighs being approxi- 
mated. Many writers have recommended heavy mechanical devices re- 
sembling fracture frames, into which the child is tied when it is put to 
bed. The profound sleep of the young child lends itself to this mode of 
treatment, and the patient quickly becomes accustomed even to such 
cumbersome appliances as double thigh splints with a separating foot- 
board. It must indeed, however, be a very severe case to justify this form 
of apparatus. 

When one has settled upon a plan for interrupting the habit, he should 
next turn his attention to the removal of all local reflex causes of irrita- 
tion. In the male infant, phimosis and preputial adhesions should be 
treated, and in the female infant the preputial hood should be separated 
from the clitoris; vulvovaginitis and all irritations of the vaginal orifice 
should be treated. Pinworms, diseases of the rectum, local eczema, and, 
in fact, all abnormalities of the rectum and genitourinary organs should 
be removed, and the child's clothing should be carefully arranged so as 
not to produce local irritation. 

Too much stress cannot be laid upon the importance of removing all 



TEEATMENT 609 

possible sources of local irritation of the nervous mechanism which con- 
trols the genital organs, as the reflex factor is not uncommonly the most 
important, not only in starting, but continuing, the habit of pseudomas- 
turbation. 

I wish, however, to call special attention to increased acidity of the 
urine as a potent reflex factor in many of these cases; I believe it is the 
most important of all reflex factors; it was present in one-third of my 
cases. This condition may be treated by benzoate of soda and tincture of 
belladonna put up in some palatable non-irritating vehicle. The alkali 
and the belladonna, the latter in small doses, should be given over a long 
period of time when there is any tendency to continuous or periodic acidity 
of the urine. 

General Treatment. — Many cases, especially those over two years of 
age, are benefited by bromid of potash and belladonna given at bedtime. 
This treatment is especially applicable in those cases where the habit is 
practiced during the night. 

An atmosphere of quiet and rest must, if possible, at all times surround 
the child. The importance of this injunction is as great in this as in the 
treatment of any other neurosis. 

By the treatment above outlined it is possible in practically every case 
to control the habit, but it must be remembered that this treatment must, 
with more or less rigor, depending upon the severity of the case, be kept 
up not only for months, but sometimes for two, three, or even four years. 
Where the treatment, however, is carefully looked after one may count 
upon a permanent cure in the great majority of cases within one or two 
years. In those that are less carefully looked after four or five years may 
be necessary to accomplish a cure. One must recognize, therefore, that 
when the above treatment has been put into operation, and the habit con- 
trolled, the patient has been placed under conditions where time, by 
strengthening the stability and inhibitory control of the nervous system, 
will accomplish a cure. It, therefore, becomes important at this stage of 
the treatment to guard carefully the child's general nutrition, treating any 
special form of malnutrition that may exist, and securing normal de- 
velopment by careful diet and proper hygienic measures, including an out- 
door life. Cod-liver oil, iron, arsenic and other tonics may enter into the 
treatment. It is important that the child should be guarded against con- 
stipation and all gastrointestinal disturbances, as attacks of this kind al- 
most always cause a recurrence of the habit in an apparently convalescent 
child. The daily bath, followed by a cold douche, has been used with 
success. 



SECTION XI 

DISEASES OF THE NERVOUS SYSTEM 

CHAPTEE LXXVIII 
DISEASES OF THE BEAIN 

INFANTILE CEREBRAL PALSIES 

Infantile cerebral palsies comprehend a group of palsies which, in their 
general clinical manifestations, are so similar that they are classed to- 
gether. They are characterized by spastic paralysis and by various other 
disturbances of cerebral functions associated with a great variety of cere- 
bral lesions. That symptoms so like in character can be produced by 
pathological lesions so unlike in character and affecting such different 
parts of the brain is due to the fact that these lesions, occurring so early 
in the life of the child, seriously interfere with the general functional 
development of the brain. These cases may be symptomatically grouped 
as hemiplegia, paraplegia and diplegia. 

Etiology. — The lesions which produce spastic paraplegia and spastic 
diplegia almost always occur at or before birth, although the symptoms 
may not appear for months later, but they never make their appearance 
after the third year. The lesions which produce spastic hemiplegia may 
occur at or before birth, but they usually occur after birth. The symp- 
toms of these postnatal palsies, as a rule, follow quickly the injury to 
the brain; in some instances, however, the palsies, if slight, may not be 
discovered for months or years later. 

Prenatal palsies are due to traumatism, such as may result from 
a blow or a fall, or to uremic convulsions or exhausting illness during 
pregnancy, and hereditary defects transmitted by neurotic or alcoholic 
parents. These exciting causes may produce cortical hemorrhage, throm- 
bosis, porencephalia, agenesis corticalis, and degeneration of the fibers of 
the pyramidal and lateral tracts. The lesions produced are usually ex- 
tensive and result in diplegia or paraplegia. 

Natal palsies are due to asphyxia, false position of the head in utero, 
and traumatism from protracted labor and the improper use of forceps. 
There is no doubt, however, that the skillful use of obstetrical forceps has 
saved many children from serious brain injury at birth; this is especially 
true in those cases in which there is a premature discharge of liquor 
amnii. The lesion is due usually to meningeal hemorrhage producing 
subsequent lesions of the cortical motor area; more rarely the hemorrhage 
is directly into the brain substance and is followed by lack of functional 

610 



INFANTILE CEREBRAL PALSIES 611 

development and by inflammatory and degenerative changes on the part 
of the brain. These cases occur much more commonly in the first-born, and 
the paralysis which follows is commonly diplegic and paraplegic, but it 
may be hemiplegic. 

Postnatal palsies are due to head injuries from blows and falls, to 
violent and protracted general convulsions, whatever may be their cause, to 
severe paroxysms of whooping-cough with the cerebral congestion which 
they produce, and to hereditary syphilis, meningitis, measles, influenza, 
and other contagious diseases. The lesions produced are cerebral hemor- 
rhage, usually cortical, rarely intracerebral, thrombosis, embolism and 
hydrocephalus. 

Pathology. — The primary lesion is usually meningeal hemorrhage, 
which may occur over any portion of the cortex. In diplegia and para- 
plegia it is bilateral, in hemiplegia it is unilateral, and is commonly 
located over the upper lateral surface of the brain, involving the motor 
areas in front of the fissure of Rolando. More rarely the initial lesion 
is an intracranial hemorrhage, a thrombus, an embolus or a chronic menin- 
gitis, producing hydrocephalus. Whatever may be the original cause, a 
meningoencephalitis occurs at the point of injury, producing softening, 
fatty degeneration and atrophy of cortical brain substance. Secondary 
sclerosis and scar tissue are in time left to mark the site of the original 
injury, and secondary degenerations may occur in the posterior and 
lateral columns of the cord. Porencephalia is very commonly found, es- 
pecially in the prenatal cases; in this condition a cyst replaces a large 
portion of the brain substance. As a result of these lesions the func- 
tional development of the brain is retarded and epilepsy and imbecility may 
result. 

The following table from Sachs, to whose careful studies we owe 
much of our knowledge of this disease, gives us an excellent classifica- 
tion of these cases from the standpoint of the age incident: 

CLASSIFICATION OF INFANTILE CEEEBRAL PALSIES (SACHS). 



Groups. 



I. Paralyses of intra- 
uterine onset. 

II. Birth palsies. 



III. Acute (acquired) 
palsies. 



Morbid Lesion. 



Large cerebral defects. (Porencephaly.) Defective (level 
opment of pyramidal tracts. Agenesis corticalis. (Highest 
nerve elements involved.) 

Meningeal hemorrhage, rarely intracerebral hemorrhage. 
Later conditions: Meningoencephalitis chronica, sclerosis, 
and cysts; partial atrophies. 

Hemorrhage (meningeal, and rarely intracerebral) ; throm- 
bosis (from syphilitic endarteritis and in marantic condi- 
tions) ; embolism. Later conditions : Atrophy, cysts, and 
sclerosis (diffuse and lobar). 
Meningitis chronica. 
Hydrocephalus (seldom the sole cause). 
Primary encephalitis; polioencephalitis acuta (Striimpeli). 



612 



DISEASES OF THE BRAIN 



Symptomatology. — Hemiplegia. — This is the most frequent form of 
infantile cerebral palsy. It may be due to brain lesions occurring at birth 
or in early childhood, and the symptoms which announce the onset of the 
paralyses differ greatly in the natal and postnatal varieties. 

When the injury to the brain occurs after birth, the most common 
period of incidence is from the sixth to the eighteenth month. The onset 
is almost always announced by severe general convulsions, which may be 
repeated at intervals over a number of days, and in the more severe cases 

an intervening coma occurs. High fever and 
vomiting usually accompany the initial convul- 
sion, and they may persist throughout the con- 
vulsive period. It is now the generally ac- 
cepted opinion that in some instances the acute 
brain lesions may be the direct cause of the 
convulsion, fever and vomiting. In other in- 
stances a severe convulsion from toxemia, 
whooping-cough or other causes may produce 
the cerebral hemorrhage, which in turn may 
directly aggravate the convulsion and other 
symptoms. In either event the onset is the 
same, and these symptoms are quickly followed 
by the characteristic paralysis. The more vio- 
lent the onset the more marked will be the sub- 
sequent paralysis. 

When the injury to the brain occurs at 
birth this fact may be announced by cyanosis 
and convulsions during the first days of life. 
Following this acute cortical irritation the 
nervous symptoms may subside and the subse- 
quent symptoms of the brain injury may await 
the development of the pyramidal tracts and 
the functional development of cortical and other 
brain centers. With the development of the 
myelin sheaths of the fibers of the pyramidal 
tracts during the first few months of life, the 
brain of the infant is put in closer communi- 
cation with the spinal cord, and, as a result, 
there may slowly develop after the third or fourth month a spastic hemiple- 
gia, or a more extensive paralysis, and late convulsive disorders may 
also occur. In some of these cases the primary injury to the brain 
may escape notice, and later an insidious spastic paralysis may de- 
velop, and the subsequent history may be very like those postnatal 
cases which are ushered in with violent convulsions, to be followed 
at once by a well-marked paralysis, except that in these latter cases the 
symptoms due to agenesis of the higher nerve centers are not usually so 
pronounced. These early symptoms in both natal and postnatal cases, 




Fig. 90. — Hemiplegia From 
Cerebral Hemorrhage. 
(Sachs.) 



INFANTILE CEREBRAL PALSIES 613 

whatever may be the character of their onset, are followed by a spastic 
hemiplegia, which may involve the face, arm and leg of one side of the 
body. It is usually more marked in the arm. The amount of incapacity 
in the paralyzed side will vary with the extent of the brain lesion. In 
mild cases it may come on after school age, and may be only a slight 
muscular weakness developed by exercise. In severe cases it may be so 
great as to render the arm and leg useless. 

Muscular contractures are the characteristic symptoms that differentiate 
this from the flaccid paralyses; the joints are bent and held more or less 
rigid; the forearm is pronated and flexed on the adducted arm, the wrist 
is drawn downward and inward, the hand is clenched, the fingers strongly 
flexed toward the palm, the knee bent, the foot extended downward and 
rotated inward, and the toes contracted. More or less recovery takes place 
in the paralyzed parts, especially in the leg, and as the patient regains the 
power of walking he has a spastic gait, dragging his toes and swinging his 
leg. In some instances fairly good control of the leg is finally obtained, 
leaving only a slight muscular weakness. But the contractures of the arm 
are more permanent. In a large percentage of the cases there develop in 
the paralyzed limb rhythmic tremor, choreiform movements, athetosis, or 
associated movements. In the latter condition the paralyzed arm imi- 
tates the movements of the good one. 

All of the reflexes in the paralyzed extremities are greatly exaggerated, 
the kneejerk being especially valuable as a diagnostic sign, a slight tap 
upon the tendon producing a maximum contraction. The Babinski and 
allied signs are usually present. There is more or less lack of develop- 
ment in the paralyzed parts as time goes on, which results in shortening 
and shrinking of the limb without muscular atrophy. All of the paralyzed 
muscles respond in a normal manner to electrical excitation. Motor aphasia 
is usually associated with right hemiplegia, but if the lesion occurs be- 
fore the child has commenced to talk, then speech is late in development. 
As Sachs has noted, however, aphasia in the young child may also be 
associated with left-sided hemiplegia. In course of time the child, as a 
rule, slowly regains or develops the faculty of speech. 

Epilepsy occurs in from 30 to 50 per cent, of these cases. It may 
begin within a few weeks after the onset of the paralysis, or it may not 
appear for years. Sachs' valuable studies have thrown much light on the 
relation of epilepsy to early spastic palsies which have disappeared, or 
which were perhaps so slight at the time as to almost escape unnoticed, 
and his advice to carefully investigate every case of epilepsy with refer- 
ence to its possible origin in an early cerebral hemorrhage will ofttimes 
reveal the cause of what would otherwise be considered as cases of idio- 
pathic epilepsy of obscure origin. Exaggerated reflexes and weak muscular 
action on one side of the body, when associated with epilepsy, are strongly 
suggestive of an early cerebral lesion. The epilepsy may be of either the 
grand mal or petit mal type. 

Feeblemindedness is one of the most frequent and distressing symp- 



614 



DISEASES OF THE BEAIN 



toms of this disease. Complete imbecility or slight mental weakness may 
result, and between these two extremes we may have every grade of mental 
defect. The most complete imbecility is usually found in the cases of 
diplegia and paraplegia. The hemiplegia cases may apparently retain 
their normal mental power, but, as a rule, they are not able to keep pace 
mentally with normal children in the severe strain that comes with ad- 
vanced school work. The mental improvement in these cases should occur 
early, if it is to occur at all, and it is futile to hope for further intellectual 

development in children eight or nine 
years of age who have been in a state 
of comparative imbecility for years. 
Deaf mutism, blindness and hemianop- 
sia may occur. 

Diplegia. — This is a double hemi- 
plegia, both arms and both legs being 
affected. It is perhaps the most com- 
mon form of cerebral paralysis during 
the first six months of life. It is pro- 
duced by natal or prenatal injuries, and 
is an extensive double, brain lesion, 
which may be marked by convulsive 
seizures during the first days of life. 
The paralysis, however, may not occur 
for weeks or months later, but never 
develops after the third year. In this 
condition the mental defects are much 
more pronounced than in hemiplegia. 
Imbecility is the rule, and with this 
hopeless lack of mental development 
there is a marked lack of physical de- 
velopment. Many of these cases never 
gain sufficient control of their legs to 
walk. Others learn to walk with a spas- 
tic crosslegged gait between the sixth 
and the ninth year of life. Epilepsy 
develops in perhaps 50 per cent, of these 
cases. Except, however, for the extent of the paralysis and the increased 
severity of all the symptoms, this form of the disease runs a course similar 
to spastic hemiplegia just described. 

Paraplegia. — Paraplegia is also a double spastic paralysis involving 
both legs, produced by a double natal or prenatal injury to the brain in- 
volving both leg centers. The lesion is, therefore, more circumscribed than 
in diplegia. Except for the fact that the paralysis is confined to the legs, 
its clinical history is very like that of cerebral diplegia. 

Monoplegia. — Monoplegia is very rare. Most of the cases which at 
first glance present this form of paralysis are old cases of hemiplegia, in 




Fig. 91. — Spastic Diplegia from 
Cerebral Hemorrhage. (Sachs.) 



INFANTILE CEREBRAL PALSIES 615 

which the leg has apparently recovered, leaving the arm contractured and 
paralyzed. A closer examination of these cases will often show a weakness 
of the muscles of the leg and exaggerated reflexes, which are indications 
of the earlier paralysis of that part. 

Prognosis.- — In diplegia and paraplegia the prognosis is invariably bad. 
Fortunately many of the most severe cases die in infancy; the others 
remain more or less hopeless invalids, incapable of mental or physical 
development. The prognosis in hemiplegia, while not good, is much bet- 
ter, especially in those cases produced by lesions occurring after birth. 
Many of these postnatal hemiplegias recover with little or no mental de- 
fect, but more or less spastic paralysis of the forearm and hand remains in 
a great majority of the cases ; but there is always a possibility that epilepsy 
may develop between the sixth and fifteenth year. The prognosis in hemi- 
plegic cases dating from birth is not so good ; in these the residual paraly- 
sis and the mental deficiency are more marked. 

Diagnosis. — The differential diagnosis of cerebral palsies from the 
other paralyses of childhood has been considered under Infantile Paralysis. 
Treatment. — In diplegia and paraplegia the underlying pathological 
lesions cannot be influenced by medical or surgical measures. It therefore 
becomes the duty of the physician to prolong the lives, modify the suffer- 
ings and control the nervous symptoms of these unfortunate children, many 
of whom live for years in a hopeless state of imbecility with fond mothers 
giving up their whole lives to care and nursing. The dietetic treatment 
is most important, since a slight constipation, intestinal fermentation, or 
a mild degree of intestinal toxemia may greatly aggravate the nervous 
symptoms, producing intense irritability, sleeplessness and even convul- 
sions. The comfort of these patients depends largely upon the ability 
of the physician to keep the gastrointestinal canal in normal condition, 
and yet so feed them that they will be properly nourished. The sedative 
treatment is also important; sleeplessness, nervous irritability, muscular 
twitchings and convulsive disorders may require the use of bromids over a 
long period of time. 

The hemiplegic cases offer a much more hopeful field for treatment. 
The convulsions and fever which mark their onset are to be treated with 
baths, ice-caps to the head, and the rectal or oral administration of chloral 
and bromids as directed under Convulsions. The subsequent treatment 
of these cases has in view the improvement of the general health of the 
child, the development of the paralyzed part, and the prevention of con- 
tractures. Good food, outdoor life, systematic massage and passive exercise 
to overcome contractures are the most important agents we have in ac- 
complishing these ends ; the massage should be general and should be given 
every other day for months or even years if necessary. Passive movements 
should be resorted to three or four times every day ; these should be gentle 
and should be directed to overcoming the contractures : the contractured 
hand, forearm and leg should be gently extended five or six times at each 
sitting. The orthopedic treatment is also most important and should be 



616 DISEASES OF THE BRAIN 

directed by an orthopedic surgeon. Properly applied braces, or the length- 
ening of and transplantation of contractured tendons, may put the child 
upon his feet, or give him better use of his arm, thus enabling him to 
expedite his recovery by active exercise. It is most important that children 
who are apparently approaching the normal in mental and physical de- 
velopment should not be pushed either mentally or physically. These 
apparently convalescent children should be carefully guarded over a num- 
ber of years until it is plain that mental training will not injure them. 
M'any of these children under the strain of school work become very 
neurotic, and, in some instances, they develop epilepsy. 

BRAIN TUMORS 

The nature and position of brain tumors in children are shown in the 
following tables from Starr : 

Position. 

Cerebellum 96 

Pons varolii 38 

Centrum ovale 35 

Basal ganglia and lateral ventricles. . 27 

Cerebral cortex 21 

Corpora quadrigemina and crura 

cerebri 21 

Base 8 

Fourth ventricle 5 

Medulla 6 

Multiple tumors 43 

Symptomatology. — The onset is insidious. The general symptoms 
develop slowly, may for a time come and go, and then gradually become 
permanent. 

Headache gradually develops, but in time it becomes very intense, re- 
curring in agonizing paroxysms, and in the interval between these severe 
attacks the pain may be dull and boring in character. Headache is one of 
the most significant symptoms, as it occurs early, is present in nearly 
every case, and increases in intensity as the tumor enlarges. It is of 
especial value in children, since headaches of this character from other, 
causes are extremely rare at this age. Vomiting usually accompanies the 
headache. It may or may not be associated with nausea, is projectile in 
character, recurs without apparent cause, and is not in any way associated 
with the taking of food. Vertigo is associated with the headache and 
vomiting. The dizziness may be slight or extreme. If the patient is on 
his feet he may stagger and fall to the floor. Vertigo may be brought on 
in these cases by changing the position of the head. It is more frequent 
and more pronounced when the tumor is located in the cerebellum or in 
the pons. General or localized convulsions of every grade of severity may 
occur. In some cases they are absent altogether. They are more common 



Nature of Tumor. 

Tuberculous tumors 

Glioma 


. .. 152 
. .. 37 


Sarcoma 

Gliosarcoma 


. .. 34 
5 


Cystic 

Gummata 


. .. 30 
2 


Other varieties * 


. .. 30 



ABSCESS OF THE BEAIN 617 

and more violent when the motor areas of the cortex are involved, and 
their diagnostic value depends largely upon their association with the 
other symptoms above noted. 

Optic Neuritis. — The occurrence of the above symptoms should sug- 
gest an examination of the eyes and, if brain tumor exists, a double optic 
neuritis will commonly be found. It occurs in 80 to 85 per cent, of ad- 
vanced cases, and is slightly more common in cerebellar tumors. Optic 
neuritis is, therefore, when taken in connection with the above symptom 
group, the most distinctive sign we have of brain tumor. It may be asso- 
ciated with partial or complete loss of sight and hearing; this combina- 
tion of symptoms should suggest cerebellar tumor. As the disease pro- 
gresses the intellect suffers, the child becomes dull, and may have but 
feeble mental capacity. Convulsions, stupor, coma and unconsciousness 
occur before death. 

Localizing Symptoms. — To the above symptom group are added the 
symptoms which resrdt from a disturbance of brain functions, which vary 
with the location of the tumor. These localizing symptoms, however, are 
the same in the child as they are in the adult, and do not, therefore, demand 
consideration here. 

Diagnosis. — Tumors should not be confused with abscess of the brain; 
the latter is an acute febrile process characterized by chills and fever and 
associated with some septic process, which can usually be located. It 
should also be remembered that brain tumors are commonly tuberculous, 
and other evidences of this disease usually precede the development of the 
brain tumors. An examination of the cerebrospinal fluid should always 
be made, as it may help to exclude the various forms of meningitis. 

Treatment. — The only cases that are at all influenced by medical treat- 
ment are those due to syphilis, and, although these are rare, it is perhaps 
advisable to give every case the benefit of antisyphilitic treatment. If 
the symptoms are not improved by a course of mercury and iodid of 
potash, then the only hope lies in surgical intervention. In most cases it 
is necessary to trephine and make an exploratory investigation before the 
advisability of a radical surgical operation can be determined upon. A 
small percentage of these cases are improved or cured by the removal of 
the tumor. 

ABSCESS OF THE BRAIN 

Abscess of the brain is a rare disease. In childhood it is usually 
secondary to chronic otitis media or mastoiditis, but may also result from 
fractures of the skull, septic processes in the frontal and ethmoid sinuses, 
and more rarely from septic foci in remote parts of the body. Abs< 3S - 
are most commonly located in the temporosphenoidal lobes, the frontal 
lobes and the cerebellum. As a rule only one abscess exists, and this may 
be so small as to almost escape observation, or so extensive as io destroy 
the greater portion of a lobe of the brain. In rare instances the abscess 
becomes encapsulated and the symptoms gradually disappear. 



618 DISEASES OF THE BRAIN 

Symptomatology. — Brain abscess commonly begins with severe pain in 
the head, paroxysmal in character, associated with projectile vomiting, 
chills and fever. Irregular septic fever, when associated with recurring 
chilly sensations, pain in the head and vomiting, is a very important symp- 
tom. If the above symptoms occur in a child suffering from disease of 
the internal ear, from mastoiditis, or septic infection of the frontal or 
ethmoidal sinuses, there is every reason to suspect that an abscess of the 
brain is developing and, if an examination of the eyes reveals an optic 
neuritis, that suspicion will, in a large degree, be confirmed. Localizing 
symptoms may also occur, such as aphasia and paralysis, or disturbances of 
function of the cranial nerves. 

Diagnosis. — In many instances it is impossible to make a diagnosis, 
but mistakes will be many times avoided by keeping in mind the acute- 
ness of the above symptom group and remembering especially that the 
headache and vomiting are associated with symptoms of general sepsis, 
such as chills, irregular fever, and a well-marked leukocytosis, and that 
the cause of this sepsis can commonly be located in the ear, mastoid or 
sinuses of the face. A careful bacteriological examination of the cerebro- 
spinal fluid should be made to exclude the various forms of meningitis. 

Course and Duration. — While the onset of abscess of the brain is not 
always sudden, after the disease is once fully developed its course is, as 
a rule, rapid, terminating, in the vast majority of instances, fatally within 
two or three weeks. The later stages of this disease are marked by sub- 
normal temperature, stupor, coma, slow pulse and marked disturbance 
of the respiratory rhythm. 

Treatment. — The treatment is purely surgical. All cases due to trauma, 
otitis media, mastoiditis and sinus affections should be operated upon at 
the very earliest time possible. Cases that cannot be relieved by surgical 
measures are to be treated in a purely symptomatic way, and opiates 
should be given, if necessary, to relieve pain. 

CHRONIC INTERNAL HYDROCEPHALUS 

Chronic internal hydrocephalus is due to increase of serous fluid within 
the ventricles of the brain, resulting in compression of brain substance 
against the bony walls of the cranium. Under this pressure the cranium 
enlarges, if bony union of the sutures of the skull has not taken place; 
this chronic internal form is commonly spoken of as "hydrocephalus" 
(Acute hydrocephalus occurs in association with meningitis, especially the 
tuberculous form, and its symptomatology is inseparably connected with 
the acute meningeal process of which it is a part, and even in those rare 
cases where the inflammation is confined to the ependyma or lining mem- 
brane of the ventricles, the clinical picture is that of meningitis, the symp- 
tomatology of which has been elsewhere considered.) In addition to the 
chronic internal form there is a condition known as chronic external hydro- 
cephalus, in which the fluid accumulates between the dura and arachnoid 



CHKOXIC INTERNAL HYDROCEPHALUS 619 

and compresses the brain against the floor of the cranial cavity ; this is an 
inflammation of the dura and arachnoid commonly associated with de- 
fective development of the cerebrum. Its comparative rarity, however, 
and the fact that its symptomatology does not materially differ from the 
chronic internal variety, are sufficient reasons for disregarding its further 
consideration. 

Etiology. — Chronic internal hydrocephalus may be congenital or ac- 
quired. Its etiological factors have not been fullv determined. Inflam- 





"i 






1 1 


'jk L 


' TBt 


\ ,*••**" ' 




^WrrW^L, 



Fig. 92. — Idiopathic Hydrocephalus. An unusual degree of cranial enlargement. Cir- 
cumference, 40 inches. (Willard Knowlton.) 

matory lesions perhaps play an important role in producing the acquired 
form, and developmental defects are believed to be etiologically related to 
the congenital form. Czerny believes that pathological changes, which 
he found in the adrenal bodies, may be a cause of this condition. The 
exciting causes, whatever they may be, in some instances close the aque- 
duct of Sylvius and the openings between the ventricles of the brain, 
thus interfering with the circulation of the cerebrospinal fluid. Xeurotic 
inheritance, congenital syphilis, and tuberculosis may be etiologicallv re- 
lated to this disease. 

Pathology. — The essential pathological condition is an accumulation 
of fluid in the ventricles, which may vary in quantity from a pint to four 
or five pints. The pressure of this fluid produces compression and atrophy 
of the brain substance. The distention is so great in severe cases that the 
brain is converted into cysts inclosed in thin walls of compressed brain 
tissue. Except in rare instances, where the sutures arc 1 firmly united, the 
skull is enlarged, and under this dilatation the sutures gap. 

Symptomatology. — The most important symptom is the increase in size 



620 DISEASES OF THE BRAIN 

of the head, which continues to grow larger as the disease progresses, 
until in a fully developed case the great increase in size of the skull is 
in marked contrast to the small, thin, wrinkled face. The forehead is 
high and pushes forward, the temporal and parietal bones spread outward, 
greatly increasing the lateral diameters of the head. The anterior fontanel 
is widely open, tense and pulsating, and the sutures leading from the 
fontanels may have opened under the pressure. The veins of the head are 
congested and prominent. The eyes protrude, are turned downward and 
have a peculiar stare, the cornea is partially covered by the lower lid, and 
the white sclera shows above; late in the disease, nystagmus, strabismus, 
and even total blindness may occur. The mentality of the child suffers as 
the disease progresses, its expression becomes dull and stupid, and it loses 
interest in its surroundings. Its body becomes more and more wasted, 
its arms and legs assume a more or less characteristic position, due to 
rigidity and contraction of the tendons and muscles. The arms are flexed, 
the fingers and toes contracted; the reflexes are exaggerated, tremor, 
choreic movements, convulsive twitchings and general eclampsia may oc- 
cur, and the patient toward the end may lie in a helpless paretic condition. 
The most pronounced and severe cases are, as a rule, of the hereditary 
form; in some of these death may occur in utero, or the head may be so 
large at the time of birth that the child dies during labor; in others the 
head is only slightly enlarged at birth, but slowly increases, until the 
characteristic symptoms are presented between the second and fourth 
months of life. 

Prognosis. — Most of these cases die in early infancy; a few of the 
milder ones recover; of those in which spontaneous cure takes place the 
majority fail to reach full mental development. 

Treatment. — In those cases in which hereditary syphilis is a factor, 
antisyphilitic treatment may favorably influence the progress of the disease, 
and since this is the only form of medical treatment that can be of any 
value, mercury by inunction and iodid of potash internally should be given 
a trial in every case where there is the slightest suspicion of syphilis. 
Lumbar puncture may in some cases give decided relief; if so, it should 
be repeated at intervals of two or three weeks. Aspiration of the ventricles 
followed by pressure bandages to the head may give temporary relief. Many 
other surgical measures have been tried, but all have been disappointing. 

MENINGOCELE, ENCEPHALOCELE, AND HYDREN- 
CEPHALOCELE 

These malformations represent different phases of congenital hernia 
of the contents of the skull. The openings through which the cranial con- 
tents protrude may be located in the occipital, the nasofrontal, the frontal, 
the temporal and parietal portions of the skull. The occipital region, 
however, is by far the most common location. In some instances a large 
portion of the occipital bone is absent, the defect extending upward along 



ENCEPHALOCELE, HYDREXCEPHALOCELE 621 

the median line to the posterior fontanel or downward to the foramen 
magnum. Through this opening the contents of the skull protrude, form- 
ing a large or small tumor mass in the median line of the lower occipital 
region. When the hernia protrudes through an opening in the nasofrontal 
region the tumor occupies the bridge of the nose. The other most common 
sites for these hernias are along the lines of the cranial sutures. 

MENINGOCELE 

Meningocele is the protrusion of the meninges or brain membranes 
through the opening in the skull. The protruding sac is commonly dis- 
tended with fluid. This is the rarest variety of cerebral hernia. The open- 
ing in the bone is usually small and the tumor mass is small, pedunculated. 





Fig. 93. — Meningocele, Encephalocele, Hydrencephalocele. 

fluctuates on palpation, is translucent, presents no pulsation and is com- 
monly reducible. This tumor mass, containing no brain tissue, is much 
more amenable to surgical treatment than other forms of "cerebral hernia; 
the sac may be opened, its contents discharged and the opening in the 
skull closed. In all instances the radical surgical treatment of this con- 
dition is to be recommended, but it is advisable to delay the operation 
for some months, until the infant, on breast-milk, has commenced to de- 
velop physically and is in a fit condition to withstand the shock of the 
operation. 

ENCEPHALOCELE 

Encephalocele is the protrusion of brain substance through the opening 
in the skull. The extruded cerebral substance carries before it the brain 
membranes. In this form of cerebral hernia the tumor mass is com- 
posed of brain substance not in communication with the ventricles of the 
brain; the only fluid that such a tumor may contain is on its outer sur- 
face between the brain tissue and the membranes covering it. In these 
cases the opening in the skull is large and the tumor comparatively small 
and not pedunculated. Pulsation in the tumor is very distinct; it is not 
translucent, and attempts at reduction are followed by symptoms of cere- 
bral compression. 

The treatment of encephalocele is very unsatisfactory; small tumor 
masses, especially in the frontal region, should be treated surgically; the 



622 DISEASES OF THE BKAIN 

sac should be opened, the tumor removed and the opening in the skull 
closed. Larger masses occurring in the occipital region are less favorable 
for operation, but, notwithstanding the great mortality which follows 
the removal of these tumors, such radical surgical measures are followed 
by a greater percentage of recoveries than follow other methods of treat- 
ment. The injection of iodin, or other irritants, as well as the expectant 
plan of treatment, offers even slighter chances of recovery. The removal 
of the tumor is to be advised in all infants suffering from encephalocele 
who have lived past the sixth month of life, and during this time have 
gained in nutrition and have commenced to show symptoms of normal 
mental development. Large tumors associated with other congenital de- 
fects occurring in infants who fail to develop both physically and men- 
tally should be considered inoperable. 

HYDBENCEPHALOCELE 

Hydrencephalocele commonly occurs in the lower occipital region; 
this is the most frequent and the worst form of cerebral hernia. The 
tumor mass in these cases is made up of brain membranes, covering the 
protruding brain substance, which contains a cavity filled with fluid in 
direct communication with the ventricles of the brain. 

As these cases are inoperable it is important that they should be differ- 
entiated from encephalocele, and this differentiation may be made with 
a fair degree of accuracy by the following symptom group: The tumor 
is large, sometimes five or six inches in diameter ; it is faintly translucent ; 
deep fluctuation is present; it is pedunculated, pendulous, irreducible, and 
its surface is irregular and offers little resistance to palpation. The skull 
is commonly deformed, giving to the eye the impression of imbecility. 
In doubtful cases deep aspiration of the tumor reveals the presence of 
fluid. 

The prognosis is absolutely bad; surgical treatment is contraindicated, 
and symptomatic medical treatment can only promote the comfort and 
prolong the life of the patient. 

IDIOCY 

Mental deficiency, imbecility and idiocy are terms used to represent 
various degrees of mental impairment due to congenital defects, disease 
and injury of the undeveloped brain of the infant, with an associated lack 
of development on the part of the general nervous system. 

Etiology. — Idiocy may be either congenital or acquired, although it 
is difficult to conform to this or any other classification in describing a 
condition with such widely varying etiological factors. 

Congenital idiocy is due to development defects of the brain, such 
as porencephalus, agenesis corticalis, and other little understood condi- 
tions. These cases represent the worst types of idiocy and are very fre- 
quently associated with other congenital malformations and with the stig- 



IDIOCY 623 

mata of degeneration in other parts of the body. They are also etiologi- 
cally related to parental alcoholism, syphilis, hysteria, insanity, epilepsy 
and chorea. It is believed that consanguinity of parents, as in the mar- 
riage of first cousins, may predispose to idiocy by exaggerating the family's 
neuropathic taint, thereby exaggerating congenital defects. Cerebral hem- 
orrhage occurring before or at birth, and followed by spastic paraplegia 
and diplegia, is one of the common causes of mental deficiency and im- 
becility (see Cerebral Palsies). Microcephalus is associated with one of 
the worst types of idiocy and hydrocephalus may produce mental defi- 
ciency and imbecility. 

The acquired forms of idiocy are due to the following causes: cerebral 
hemorrhage, meningitis, encephalitis, epilepsy, eclampsia, traumatism and 
asphyxia. 

Symptomatology. — Mental deficiency, no matter how marked it may 
be, is rarely recognized during the first months of life, except in the Mon- 
golian type of this disease. Defective infants are believed to be normal 
in the great majority of instances, until the time arrives when it is evi- 
dent, even to the mother, that the infant does not handle its body, use its 
arms and legs, and otherwise act as normal infants do. When it is per- 
haps six months of age the attendants notice that its body is limp, and 
that it makes no effort to hold up its head or straighten its spine. As 
time passes it may become evident that the infant fails to distinguish 
between the faces that constantly surround it; it does not recognize its 
mother. During the second year of life, instead of uttering words that 
have been repeated to it, it makes strange sounds or perhaps utters shrill 
cries, and all of its actions are without purpose or intent. It fails to 
grasp at or take hold of its nursing bottle, is unable to lift itself in bed, 
and, even toward the end of the second year, makes no effort to walk. In 
the early stages of this condition these signs of lack of physical develop- 
ment are more evident than symptoms due to lack of mental development, 
but as the child grows older the mental defects become evident. The facial 
expression in almost every instance bears the mark of stupidity and lack 
of intelligence to everyone except the mother, and perhaps those who have 
been constantly associated with the child from birth. On the one hand 
the child may be stupidly amiable, never crying, easily amused, knowing 
no fear, making friends with everyone, and quite as happy when amused 
by strangers as when it is with its mother; or again it may be irritable, 
easily frightened and uncontrollable. The degree of mental deficiency will 
vary greatly with the extent and severity of the brain injury which pro- 
duces it. In many of the acquired cases, especially those associated with 
cerebral hemiplegia, the child has a fair degree of intelligence, and the 
mental development in these cases may be greatly improved by careful, 
systematic training. In other instances, especially those associated with 
congenital brain defects, intellectual activity may be almost or totally 
lost. Such cases have no idea of personal cleanliness, eat their food in 
a ravenous manner when it is fed to them, fail to acquire the faculty of 
41 



624 DISEASES OF THE BBAIN 

speech, and make strange uncouth noises that have no relevancy to their 
surroundings. 

Prognosis. — The prognosis in all of these cases is bad so far as total 
recovery is concerned, but from the standpoint of partial recovery the 
prognosis depends upon the character and extent of the lesion. The con- 
genital cases due to defective development of the brain are hopeless. Those 
due to cerebral hemorrhage and associated with diplegia and paraplegia 
are also hopeless, but those associated with hemiplegia, as previously noted 
under Cerebral Palsies, may have a fair degree of development. Those 
due to inflammatory conditions of the brain and meninges may be only 
partially defective, and those cases associated with epilepsy may suffer 
from very slight or very marked mental deficiency. 

Treatment. — Hopeless cases are better cared for in institutions, where 
they will be much happier than in their own homes, and where they will 
not have an unfavorable influence upon the other children in the family. 
Feebleminded or slightly defective children should be placed under the 
care and direction of teachers who have been especially educated for this 
kind of work. Under the care of intelligent specialists the best possible 
results in the mental development of these children can be obtained. 
The late Dr. Christopher, of Chicago, did excellent service by helping to 
establish a special system of education for defective children in connection 
with the public schools of Chicago. These defectives were separated from 
the normal children in the public schools, were properly classified and 
placed under competent instructors. Nearly all of the large cities of our 
country are beginning to recognize the importance of furnishing to the 
defective children of the poor an education which will develop the best 
that is in them and possibly make them self-supporting in after life. 

AMAUROTIC FAMILY IDIOCY 

The etiology of this condition is unknown; it is congenital, and, al- 
though a rare disease, more than one case may occur in the same family. 

At birth the child is apparently healthy, but at six or eight months 
of age physical and mental defects are observed. It does not use its body 
and limbs as normal children do, and shows absolutely no sign of mental 
development. Nystagmus occurs and blindness gradually results from 
atrophy of the optic nerve. An ophthalmoscopic examination shows red 
spots on a gTayish-white opacity in the region of the fovea centralis. A con- 
dition of absolute idiocy is presented, the child has no mental perceptions, 
spastic paraplegia may develop, progressive emaciation occurs, and the 
disease invariably ends in death, usually before the end of the second year. 

MONGOLIAN IDIOCY 

The cause of this condition is unknown, but its most striking symp- 
tom is the facies, which is characteristic of this disease, and by it the 
diagnosis is made. The facies consist in a Mongolian or Chinese type of 



IDIOCY 625 

face, characterized by the downward slant of the palpebral fissures toward 
the nose, which is broad and low. The cheeks are full and high-colored; 
the skin and hair normal; the tongue, although not swollen, lolls out of 
the mouth as it does in the cretin. The head is flat, the fontanels remain 
open longer than usual, and the skull is brachycephalic and below the 
average in circumference. The hands are short ; this is especially noticeable 
in the thumb and little finger; the latter curving inward over the ring 
finger is a sign of diagnostic importance in differentiating this disease 
from cretinism. The characteristic facies above described may be notice- 
able soon after birth, and by it the physician may be able to foresee the 
subsequent development of Mongolian idiocy. 

These Mongols as they grow older show not only delayed physical de- 
velopment but marked lack of mental power. They teethe slowly and are 
late in getting control of their arms, legs and body, so that they may be 
four or five years of age before they walk with ease. From this time on 
their mental defects are much more noticeable, but, as a rule, they con- 
tinue to slowly improve in intellectuality, being classed as very backward 
children. At three or four years of age they may understand what is said 
to them: be able to repeat simple words, play with their toys, be inter- 
ested m their surroundings, and may finally reach a stage of mental de- 
velopment which enables them to look after their personal wants, observe 
ordinary habits of cleanliness, and even learn to read and write, but be- 
yond this little is to be hoped for. 

Treatment. — There is no medical treatment that favorably influences 
this condition. The treatment of these children, therefore, consists in 
looking carefully to their mental and physical development. Their men- 
tal development can be favorably influenced by placing them under the 
care and direction of competent teachers, who have been trained for this 
work. 

MICROCEPHALIC IDIOCY 

In this form of idiocy the head presents a characteristic deformity. 
The circumference of the cranium is small, the forehead is very low and 
sharply recedes into a poorly developed occipital prominence, the fontanels 
are closed, the sutures prematurely ossified, and the face is proportion- 
ately large, giving the head a peculiar bird-shaped appearance, stamped 
with an expression of absolute idiocy. The primary pathological lesion 
in these cases is situated in the brain; a microcephalic brain may even be 
incased in a normal cranium. The small skull in most of these cases has 
absolutely nothing to do with arresting the growth of the brain. The ar- 
rested development of the brain, like the perverted development of the 
cranium, is due to developmental defects. In some instances there may 
be a lack of development of the whole brain. In other cases tin 1 occipital, 
the parietal or the frontal lobes may be undeveloped, and the small and 
prematurely ossified cranium is, as a rule, more commodious than the 
atrophied brain demands. Operation upon the skull, to increase the capacity 



626 MENINGITIS 

of the cranium and allow the brain to grow, is founded upon an erroneous 
conception of this disease, and does absolutely no good. 

Microcephalic idiocy, as the term is commonly used, merely refers to 
a type of hopeless and almost complete idiocy in which the atrophied, 
diseased and deformed brain is inclosed in a microcephalic skull and does 
not definitely determine the character or location of the brain deformity. 
The multiplicity of brain lesions which exist in these cases explain the 
fact that in some instances the rest of the body may be normally developed 
and the patients may live past middle life, while in other instances spas- 
tic and flaccid paralysis may exist and the duration of the disease may be 
much shorter. 

Treatment. — There is no treatment, either medical or surgical, that 
favorably influences the course of this disease. 



CHAPTER LXXIX 
MENINGITIS 

Meningitis is an infectious disease producing inflammation of the pia 
mater and arachnoid membranes of the brain and spinal cord. For clin- 
ical reasons the various forms of this disease are here grouped under one 
heading. 

In the present state of our knowledge it is impossible to make a satis- 
factory clinical classification of the different forms of meningitis. The 
syndromes presented by the various forms so closely resemble one another 
that a classification based on clinical phenomena alone is absolutely im- 
possible. In this dilemma it is perhaps better for text-book purposes to 
adopt the classification now in vogue based upon clinical, bacteriological 
and pathological findings. It recognizes three varieties, the differential 
diagnosis of which can nearly always be made by an examination of the 
cerebrospinal fluid, studied in connection with the clinical syndromes 
which the various forms of meningitis present. 

This classification is as follows : 

1. Tuberculous meningitis, produced by the tubercle bacillus. 

2. Epidemic cerebrospinal meningitis, produced by the meningococcus 
intracellularis. 

3. Purulent meningitis, a term used to include all forms not produced 
by the tubercle bacillus or meningococcus. 

TUBERCULOUS MENINGITIS 

Pathology.— This form of meningeal inflammation is produced by the 
tubercle bacillus and its general etiology is the same as that of other forms 
of tuberculosis. The meninges are soon studded with small gray tubercles 
usually attached to the blood vessels. A thick, yellow, inflammatory exu- 



TUBERCULOUS MENINGITIS 627 

date forms over the base of the brain, and extends with the blood vessels in 
the sulci which lead toward the convexity of the brain. The ventricles 
are distended, producing internal hydrocephalus; the gradually increasing 
hydrocephalus produces intracranial pressure, pushing with considerable 
force the convolutions of the brain against the unyielding bony wall of the 
cranium. The brain tissue just beneath the meninges may contain caseous 
nodules which sometimes reach the size of a hen's egg. These tubercu- 
lous tumor masses may produce localizing symptoms. The meningeal in- 
flammation may not only involve the cervical region of the cord, but may 
extend along the entire spinal canal. 

Tuberculous meningitis occurs most frequently in infancy and early 
childhood; about 70 per cent, of the cases are seen between the end of the 
first and the fifth years of life. It is the cause of death in 20 to 30 per 
cent, of all cases dying of tuberculosis under five years of age, and at this 
period of life it comprises about 70 per cent, of all cases of meningitis, 
except when the epidemic form is prevalent. It is commonly secondary 
to lymph-node, pulmonary, and general miliary tuberculosis, but may re- 
sult from tuberculous foci anywhere in the body, the blood and lymph 
streams being the carriers of the tubercle bacilli to the meninges; in 
nearly every instance the infecting organism is of the human type. It is 
rarely, if ever, a primary disease, but may spread from bony cavities in 
the face, nose and ear, with no preliminary tuberculous disease elsewhere 
in the body. 

Symptomatology.' — In infancy tuberculous meningitis is commonly a 
manifestation of a general tuberculosis and is not, as a rule, preceded by 
premonitory symptoms due to tuberculosis elsewhere in the body. After 
the second year of life, however, it is generally very insidious in its onset 
and is preceded by the symptoms of lymph-node, bone, lung or general 
miliary tuberculosis. Its symptoms, especially in children over three years 
of age, may be divided into three groups representing the stages of in- 
vasion, irritation and compression. It must be remembered, however, that 
while the symptoms, for clearness of presentation, are here described under 
these three groups, the symptomatology of this disease does not by any 
means always follow this regular course. On the other hand, the variabil- 
ity and irregularity of the symptoms are notable characteristics of tuber- 
culous meningitis. 

The stage or invasion is marked by fever, vomiting, constipation, 
great nervous irritability, sleeplessness, loss .of weight and general pros- 
tration, none of which are especially characteristic of this disease: but a 
combination of some or all of these symptoms is especially suggestive 
when they occur in a child who has tuberculous foci elsewhere in the body. 
or who has lived under conditions which have repeatedly exposed it to the 
tuberculous contagion. The vomiting occurring and recurring without 
apparent cause is the symptom which gives special importance to this symp- 
tom group. The temperature during this period is usually overlooked, 
and varies from normal to 101°F. The Moro and von Pirquet skin re- 



628 MENINGITIS 

actions are nearly always present during this stage. These symptoms may 
continue, especially in older children, two or three weeks, and during this 
time the child may have days of apparent convalescence, but its general 
condition steadily grows worse until the stage of irritation presents the 
following more characteristic symptoms : An increase in the fever to 
101° or 102 °F. occurs, but the temperature, as a rule, does not run high 
unless there be other tuberculous lesions. The restlessness gives way to 
mental dullness and stupor, which may alternate with extreme nervous 
irritability and may be associated with a mild delirium; convulsions, 
either general or local, may occur; muscular rigidity, producing retraction 
of the neck and stiffness of the spine, appears; localized facial palsy and 
spastic paralysis of the extremities may come and go; Kernig's sign is 
present sooner or later in the majority of cases, but is not so frequent as 
in other forms of meningitis; Babinski's reflex is slightly more common 
in this form of meningitis than in any other, and is, therefore, in chil- 
dren over two years of age, a sign of some value in differential diagnosis. 
The pupils may be unequal and respond slowly or not at all to light; 
strabismus is a common and a very suggestive sign; nystagmus may be 
noted among the earliest eye symptoms, and the ophthalmoscope may reveal 
an optic neuritis with bright shining tubercles in the choroid. Vaso- 
motor disturbances are common, red patches involving the ear or other 
portions of the body may come and go without apparent cause, and a red 
streak may be brought out by drawing the finger over any portion of the 
body; the petechial eruption is absent. The respiratory rhythm is dis- 
turbed; the respirations are irregular and marked by periods in which the 
respiratory movements are suspended; gradually a Cheyne-Stokes type of 
breathing may be developed. The pulse may be slow and intermittent. 
This stage may last a week, more or less, depending upon the age of the 
child and the severity of the disease. During this time there may be great 
variations in this symptom group. It is not an uncommon experience to 
find that a child that has been for a number of days profoundly stuporous 
and almost or quite unable to swallow food, rather suddenly recovers 
consciousness and again swallows his food in a normal manner. This ap- 
parent improvement causes the attendants to hope that the child is really 
better, when after a few hours the stupor returns and the whole symptom 
group gradually grows worse, until the third stage of the disease arrives 
with symptoms of cerebral compression. The coma deepens; unconscious- 
ness is complete; the muscular spasm is relaxed; stiffness of the muscles 
of the spine disappears; general paralysis, permanent, and of the flaccid 
type, is widespread; deglutition becomes more difficult and at times im- 
possible; the eyelids are partially closed, the pupils widely dilated, and the 
eyeballs turned upward. The pulse is very rapid and weak; the breathing 
becomes more rapid, more irregular, and the respiratory pauses are more 
noticeable. The temperature, which has run a low range throughout the 
disease, rarely rising above 102° or 103 °F., toward the end of the disease 
may rise to 105° or 106 °F. A deepening coma not infrequently accom- 



TUBEECULOUS MENINGITIS 



629 



panied by convulsions terminates the clinical picture. This stage lasts 
from a few days to one week. 

The above symptom group is subject to many variations, largely de- 
termined by the age of the child and the virulency of the pathologic 
process. The average duration, not counting the vague prodromal symp- 
toms, is two weeks in young infants and three weeks in older children; 
other things being equal, the younger the child the more rapid and the 
more violent will be the course of the disease. 

Diagnosis. — The diagnosis of tuberculous and other forms of meningitis 
depends upon the careful study of the above symptom group in connection 
with the individual case; giving special attention to the family history, 



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Fig. 94. — Tuberculous Meningitis in Child Twenty Months Old. 

the opportunities for contracting the tuberculous contagion, the presence of 
tuberculous foci elsewhere in the body, the slow onset of the disease, the 
low range of temperature, the character of the breathing, the eye symp- 
toms, the ophthalmoscopic findings, the presence of Moro's and von Pir- 
quet's tuberculin skin reactions in the early stages, and, most important of 
all, the finding of tubercle bacilli in the cerebrospinal fluid; with careful 
technique this may be accomplished in the majority of cases. The diag- 
nosis may still further be confirmed by producing tuberculosis in the 
guinea pig by inoculating it with the cerebrospinal fluid. 

Concerning the diagnostic importance of a careful examination of the 
cerebrospinal fluid, Dunn states that: "The order in which the inferences 
are made during such an examination is as follows: if the fluid is cloudy, 
some form of meningitis is present; if clear, no form of meningitis ran 



630 MENINGITIS 

be present, except the tuberculous. If the cell count is normal (under 
ten per cubic millimeter), no meningitis is present; if the cell count is 
increased (over ten per cubic millimeter and usually over one hundred per 
cubic millimeter), some form of meningitis is present. If, with menin- 
gitis present, the predominating cell is the mononuclear lymphocyte, the 
evidence points toward the tuberculous form; if the predominating cell is 
polymorphonuclear, the evidence points toward some other form. The 
differentiation of these other forms depends on the finding of the specific 
etiologic microorganisms in the cerebrospinal fluid. The diplococcus 
intracellulars and the influenza bacillus are recognized by their morphology 
and their Gram-negative staining reaction; the former also is frequently 
seen within the leukocytes. The pneumococcus, streptococcus, and staphy- 
lococcus are recognized by their morphology, and their Gram-positive 
staining reaction.- The tubercle bacillus is recognized by its special staining 
reaction. The chief difficulty is in distinguishing the pneumococcus from 
the staphylococcus form, from the fact that the former frequently shows 
a chain formation, and its capsule is difficult to demonstrate in the cerebro- 
spinal fluid. Nevertheless, this difficulty is not so great in the cerebro- 
spinal fluid as under some other conditions. In meningitis the streptococ- 
cus usually forms long chains and its morphology is unmistakable, while 
the pneumococcus frequently is seen in short chains; its typical form as 
a lance-shaped diplococcus is usually plainly evident. The positive proof 
of the existence of tuberculous meningitis is also often difficult, as bacilli 
cannot always be found. We are obliged to depend on the increased cell 
count, with the preponderance of lymphocytes. Where the cell count is 
only moderately increased some doubt of the diagnosis will remain. Also 
the cell count in the cerebrospinal fluid is increased in some other condi- 
tions which, however, are not of a kind usually mistaken for tuberculous 
meningitis. The existence of an increased number of mononuclear cells 
is sufficient for ordinary clinical purposes, but if the bacilli are not found, 
it cannot be taken as absolute proof sufficient for scientific purposes/' 

Prognosis. — This is almost hopeless. A very few cases of recovery, 
however, with well-established diagnoses, are reported each year. 

Treatment. — Since under existing forms of treatment the prognosis in 
these cases is almost hopeless, they should be treated symptomatically, as 
outlined under meningococcus meningitis. The specific serum, however, of 
this latter disease is of absolutely no value in the treatment of any other 
form of meningitis. The possibility, however, that there may be a mistake 
in diagnosis, and the fact that a small percentage of cases of tuberculous 
meningitis recover, should stimulate the physician to the application of all 
remedies which ameliorate symptoms and prolong life. Early and repeated 
lumbar puncture is believed by Dunn to exercise a favorable, and perhaps 
a curative, influence in rare instances. 



MENINGOCOCCUS MENINGITIS 631 



MENINGOCOCCUS MENINGITIS 

Meningococcus meningitis is an acute infectious, feebly contagious 
disease caused by the diplococcus intracellulars meningitidis. It occurs 
both sporadically and epidemically, and is characterized by a general sys- 
temic intoxication and the symptoms of a violent inflammation of the 
pia mater and arachnoid membranes of the brain and spinal cord. 

Etiology. — The specific microorganism of this disease was first de- 
scribed by Weichselbaum in 1887. It is found in the mucous discharges 
from the nose and throat, in the blood and in the cerebrospinal fluid of 
infected individuals, and may also be demonstrated on the mucous mem- 
branes of the throat and nose of healthy individuals, who are closely as- 
sociated with patients ill of this disease. These "meningococcus carriers," 
it is believed, may carry the infection to susceptible individuals. It is 
thought that this diplococcus finds its portal of entrance to the human body 
through the nose and throat, and is disseminated by the mucous discharges 
from the respiratory passages or by the careless handling of cerebrospinal 
fluid drawn for therapeutic or diagnostic purposes. But, notwithstand- 
ing the apparent danger of spreading the disease in this way, long experi- 
ence has taught that there is little actual danger from contact contagion 
such as exists in the other acute infections. That the disease is but feebly 
contagious is demonstrated by the fact that these cases have always been 
treated in the general wards of our hospitals, and until the discovery of 
its specific cause, clinicians had scarcely suspected that there was any great- 
er danger of direct contagion from this form of meningitis than from any 
other. The slight contagiousness may be due to the lack of individual sus- 
ceptibility and to the "brief vitality" of the specific contagion. On the 
other hand, one must recognize the fact that the contagion is at times 
very widely disseminated, producing extensive epidemics. Minor epi- 
demics have occurred in all of our large cities, and have also been reported 
from country districts and small towns remote from great centers of popu- 
lation. In the intervals between these epidemics the disease occurs sporad- 
ically throughout the land, now and then appearing in different parts of the 
same city, or perhaps as isolated cases in lone farm houses. The prankish 
vagaries of this contagion are yet to be explained. 

Age. — The disease is rare in infancy, although Rotch reports a case 
in an infant six days old. After the first year of life, however, it is not 
uncommon, and childhood is the period of greatest susceptibility. It is 
comparatively infrequent in the adult. 

Season. — It occurs most commonly in the spring of the year; more 
cases are seen during March and April. It is less commonly observed 
during the summer months. It is believed that the low vitality of children 
at this period of the year may make them more susceptible. 

Pathology. — This disease is characterized by an infection of the pia 
mater and arachnoid with the encapsulated diplococcus of this disease. 



632 MENINGITIS 

These microorganisms are found in the polynuclear leukocytes which are 
thrown out in great numbers, and in the cerebrospinal fluid which is greatly 
increased in quantity. These brain membranes are in the beginning in- 
tensely congested, and this hyperemia is followed by a serofibrinous and 
seropurulent exudate which collects at the base of the brain and in the 
ventricles and may extend over the cortex and down the spinal canal. The 
fluid found in the ventricles and cerebrospinal canal quickly becomes 
clouded with pus corpuscles, and later may become a distinctly purulent 
fluid. 

In the foudroyant cases the patient may die before the inflammatory 
lesions are marked. In such eases the brain membranes may show only 
intense congestion with a serous exudate. In the less severe cases the 
process lasts longer and a decidedly purulent exudate may be present. In 
the more or less chronic cases lasting for weeks the pia mater and arach- 
noid are thickened and bound to the brain by an inflammatory exudate. 

Symptomatology. — Onset. — In Huber's careful analysis of 100 cases, 
only 3 presented prodromal symptoms. In these the more acute symp- 
toms were preceded, by a few hours, with malaise, headache, loss of appe- 
tite, indefinite pains, chilliness and slight rise of temperature. In all of 
the others the onset was sudden, and in many the exact hour when the 
acute symptoms began was named. There is perhaps no other disease in 
which the onset is so uniformly sudden and violent as it is in cerebrospinal 
meningitis. The disease commonly begins with vomiting, chilliness, severe 
headache, and rapid rise of temperature. To this symptom group is some- 
times added convulsions, which are especially common in young children. 
A petechial eruption may occur. Spinal pain and tenderness associated 
with general hyperesthesia may cause the patient to cry with pain whenever 
he is touched. These symptoms are followed by tenderness and retrac- 
tion of the postcervical and spinal muscles (opisthotonos), extreme nerv- 
ous irritability and muscular tremor. Delirium quickly develops, and in 
severe cases this is followed by stupor, coma, convulsions and death. In 
the milder cases the same symptoms mark the onset, but the subsequent 
course of the disease is less severe. Fatal cases may begin with compara- 
tively mild symptoms, and cases that recover may have a violent onset, 
but, on the whole, a severe initial general toxemia is commonly followed 
by a severe inflammation of the brain and cord. In older children the vio- 
lence of the onset is more directly in proportion to the severity of the sub- 
sequent symptoms than it is in infants, to whom the open fontanels furnish 
a certain degree of protection from the early pressure symptoms of this 
disease. 

Vomiting, which is commonly the initial symptom, is projectile in 
character and may persist for a number of days, but rarely continues 
throughout the attack. It is usually associated with constipation. 

Nervous Symptoms. — The headache which is an early symptom is 
usually intense and is usually frontal, but may involve other portions of 
the head and may be associated with restlessness, irritability and photo- 



MENINGOCOCCUS MENINGITIS 633 

phobia. The postcervical and spinal muscles become tense and tender and 
more and more retracted until a marked opisthotonos is produced. Irri- 
tation of the sensory roots of the spinal nerves produces tenderness on 
either side of the spine and a more or less general hyperesthesia of the 
skin, which causes the patient to cry out with pain when touched. The 
irritation of the motor nerves, which produces retraction of the head and 
backward curvature of the spine, may also produce a tonic contraction 
of the muscles of the arms or legs, resulting in the drawing up, under more 
or less tension, of these extremities. The reflexes associated with menin- 
geal irritation are well marked. Kernig's sign is rarely absent. The 
Babinski reflex, which is of little value in children under two years of 
age, can usually be demonstrated, and the tache cerebrale is present. 




Fig. 95. — Opisthotonos in Cerebrospinal Meningitis. 

These reflexes, while of importance in confirming the diagnosis of menin- 
gitis, are of little value in differentiating this from other forms of menin- 
geal inflammation. Delirium, following chilly sensations, is an early and 
common symptom; in the milder cases it may quickly subside, and the 
patient may remain conscious throughout the course of the disease. In 
the more severe cases the delirium may become so violent that restraint 
is necessary, and stupor and coma may supervene. The patient may come 
out of the coma to again become actively delirious, and this delirium may 
gradually subside as convalescence is established. A prolonged comatose 
condition not infrequently occurs in fatal cases. 

Fever. — With the onset the fever rises suddenly. Within the first 
twenty-four hours it may reach 104° or 105 °F. This sudden rise in the 
temperature, accompanying the initial symptoms of vomiting and head- 
ache, is of diagnostic importance, but thereafter the temperature curve is 
of little diagnostic or prognostic importance, as it is subject to such varia- 
tions. After the initial rise, the temperature may fall almost to normal 
within a few days. Again it may rise to 104° or 105 °F., and its subse- 
quent irregularities, which may include subnormal temperatures, followed 
by high fever, give little information as to the progress of the disease. In 
prolonged cases the temperature may continue for many weeks and even 
months. 

The pulse in children is rapid, commonly ranging between 120 and 
160. Respiration is accelerated; as the disease advances it may become 
irregular, and Cheyne-Stokes breathing rarely occurs. 



634 



MENINGITIS 



A 'petechial eruption may occur as dark-red points widely disseminated 
over the skin of the entire body; being hemorrhagic in character, it does 
not disappear on pressure. It may be preceded or followed by a diffused 
mottling of the skin or by an erythematous rash. Herpes about the lips 
or other portions of the face may occur. Bed sores are not uncommon in 
chronic cases. 

Pronounced nutritional disturbances occur early and continue through- 
out the disease. Emaciation and loss of strength are rapid and progres- 
sive. 

Blood examinations show a marked polymorphonuclear leukocytosis, 
which, according to Huber, varies from 18,000 to 40,000. 

Differential Diagnosis. — Lumbar puncture enables us to make an accu- 
rate diagnosis in this form of meningitis. The cerebrospinal fluid ob- 



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tained early in this disease always contains the diplococcus intracellularis, 
either free or within the polynuclear leukocytes which predominate in this 
fluid. They may be demonstrated by microscopical examination of the 
sediment obtained by centrifuging the fresh cerebrospinal fluid or by 
examining cultures inoculated with this fluid. The finding of these diplo- 
cocci establishes beyond a doubt the diagnosis of meningococcus meningitis 
and, if the technique be accurate, the failure to find these organisms during 
the first week precludes this diagnosis. As the disease progresses the find- 
ing of diplococci in the cerebrospinal fluid becomes slightly less certain, 
so that after the first week a number of negative findings is necessary to 



MENINGOCOCCUS MENINGITIS 635 

justify the conclusion that the disease is not meningococcus meningitis. 
It is quite impossible to make an accurate differential diagnosis between 
the different forms of meningitis in any other manner than by a careful 
examination of the cerebrospinal fluid, and yet there are differences in 
the clinical syndromes of the most common forms of meningitis which, 
when carefully studied, may materially assist in making the differential 
diagnosis. The onset in tuberculous meningitis is commonly insidious, 
and that of meningococcus meningitis is sudden and tumultuous. In 
meningococcus meningitis the initial high fever, the pronounced hyper- 
esthesia, the high leukocyte count, and the well-marked retraction of the 
head and posterior spinal curvature are in contrast to the slight fever, the 
absence of hyperesthesia, the low leukocyte count, the slight retraction of 
the head, and the tuberculin skin reaction which are commonly present in 
tuberculous meningitis. By contrasting these symptom groups and care- 
fully inquiring into the previous personal and family history of the pa- 
tient, and by further considering the fact that in the absence of an epi- 
demic of meningococcus meningitis, the tuberculous is much the most com- 
mon form of this disease, one can, as a rule, rather definitely differentiate 
the tuberculous from the meningococcus type (see Tuberculous Meningitis). 

Complications. —Conjunctivitis, otitis, and pneumonia are the most 
common complications. 

Sequelae. — In cases not treated with the Flexner serum from 20 to 30 
per cent, of those that recover have more or less serious sequelae. The most 
dreaded after-effects are deafness and mental deficiency. Chronic hydro- 
cephalus, blindness, and various forms of paralysis (cerebral, spinal, and 
peripheral) may also result. Under the influence of the Flexner serum, in 
the cases that recover, the cure is usually complete ; rarely, permanent deaf- 
ness may result. The joint affections, which sometimes result, can, as Ladd 
and Netter have shown, be favorably influenced by direct injection into the 
inflamed part, of the antimeningitis serum. 

Course and Duration. — Malignant cases may run a very rapid course 
with wild delirium, coma, and opisthotonos, ending fatally in a few days. 
In the great majority, however, the ordinary course of the disease is pro- 
tracted, lasting for weeks, and in the chronic cases for months. In those 
cases that recover convalescence is slow, many months being required to 
restore the child to its normal condition. Under the Flexner serum the 
course of the disease is materially modified, its duration shortened, and 
convalescence is much more rapid and complete. In these cases the aver- 
age duration is now believed to be less than two weeks. A marked improve- 
ment in the patient's general condition is often seen within twenty-four 
hours, although rigidity of the neck and Kernig's sign may persist for many 
days. 

Prognosis. — The younger the child the greater the mortality. Very 
young infants not treated with the Flexner serum rarely recover. Sporadic 
cases are commonly milder in type than those that occur during epidemics. 
The general mortality in the past has varied from 70 to 85 per cent. The 



636 MENINGITIS 

indications now are that under the serum treatment this mortality will be 
reduced to 25 or 30 per cent. 

Prophylaxis. — In the light of our present knowledge of the etiology of 
the disease, and from the fact that a number of persons in the same fam- 
ily are not infrequently affected, it is obligatory for the physician to as- 
sume its contagiousness. The sick should be isolated from the well and 
all catarrhal discharges from the throat and nose of the patient should 
be disinfected. The cerebrospinal fluid drawn by lumbar puncture should 
be so handled that it may not infect the surroundings of the patient, and 
all individuals coming in contact with the sick should wash their throats 
and nasal passages once or twice a day with an alkaline antiseptic solution. 

Treatment. — Serum Treatment. — The antimeningitis serum developed 
by Simon Flexner is now looked upon as the specific treatment for this 
disease. Its use has been followed by remarkably curative results. It is 
produced in the horse by inoculation of the animal with the diplococcus 
intracellularis and its products. In suspicious cases if the cerebrospinal 
fluid is cloudy, the serum is to be immediately introduced into the cerebro- 
spinal canal. Subsequent doses are to be given if the diplococcus intra- 
cellularis is demonstrated in the cerebrospinal fluid, or if the first dose is 
followed by apparent improvement in the symptom group. 

Technique of Administration. — The serum is injected into the spinal 
canal. It is furnished in bottles containing 15 c. c. and is stored at 
refrigerator temperature, so that great care must be taken to have the 
serum warmed to body temperature before it is injected. Lumbar punc- 
ture is made under strict aseptic precautions, and all of the cerebrospinal 
fluid that will run freely is carefully collected and measured. When the 
flow has stopped, a syringe containing an amount of serum about equal to 
the amount of cerebrospinal fluid that has escaped is attached to the same 
needle, and through it the contents of the syringe are slowly injected into 
the spinal canal. The fluid should flow from the syringe without resistance ; 
forcing the fluid into the canal under pressure is fraught with danger. 

Dose. — The average initial dose is 30 to 40 c. c. In very severe cases 
and in older children this dose may be increased to 45 c. c, provided this 
amount of serum can be injected without undue pressure; occasionally 
a quantity of serum greater than the amount of cerebrospinal fluid with- 
drawn may be injected without resistance. It is commonly necessary to 
inject 30 c. c. of the serum daily for four or five days, and this routine 
is followed in the treatment of the average case, unless the symptoms 
quickly disappear under the treatment. In the event of a quick response to 
treatment the interval between the injections may be two or three days, and 
they may be discontinued when convalescence is apparently established and 
the diplococci have disappeared from the cerebrospinal fluid. If relapses 
occur and diplococci reappear in the cerebrospinal fluid of cases that have 
been apparently convalescent, the serum treatment is to be begun again. 
The number of doses and the frequency of the dose can be determined 
only by the manner in which the disease responds to the treatment. As 



MENINGOCOCCUS MENINGITIS 637 

long as symptoms are present, and diplococci are found in the spinal fluid, 
the serum injections are to be continued at intervals depending upon the 
severity of the symptom group. 

Results Obtained. — Flexner furnishes the following table of cases treated 
with antimeningitis serum : 

"Table of Cases of Epidemic Cerebrospinal Meningitis Treated with the Anti- 
meningitis Serum. 

Cases Analysed According to Age Groups. 

Per cent. 

Age Years. Total No. Cases. Eeeoverecl. Died. Mortality. 

1-2 104 60 44 42.3 

2-5 112 82 30 26.7 

5-10 113 95 18 15.9 

10-15 101 73 28 27.7 

15-20 107 72 35 32.7 

20+ 175 106 69 39.4 

Total, all ages 712 488 224 31.4 

"This table brings out several points of interest. The highest mortality 
is shown to have occurred in the first two years of life. But, contrary to the 
rule under the older forms of treatment in which the mortality was 90 per 
cent., or over, in this series it w T as 43.3 per cent. The second age period is 
from 2 to 5 years, in which the mortality was 26.7 per cent. The third age 
period embraces children from 5 to 10 years of age and gave the lowest 
mortality of all, namely, 15.9 per cent. The next period extends from 10 
to 15 years and gave a mortality of 27.7 per cent. The next period of 
from 15 to 20 years showed a considerable rise in mortality, equaling 32.7 
per cent., and the last period, embracing the cases of 20 years and over, gave 
a mortality of 39.4 per cent. The average mortality in all the age periods 
was 31.4 per cent." 

The following table from the same source shows the, great advantage 
to be obtained by the early use of the serum and impresses the importance 
of early diagnosis and early serum treatment : 

Period of Injection of Serum. Cases 

First to third day 123 

Fourth to seventh day 126 

Later than seventh day 112 

The specific action of the serum is also shown by the fact that in 25 
to 30 per cent, of the cases treated, the disease terminated by a crisis fol- 
lowing the injection of the serum. 

Mode of Action. — The serum is bacteriolytic and but feebly antitoxic. 
It acts by destroying the diplococcus. This diplococcus furnishes no extra 
cellular toxins. Its toxins are entirely intracellular and are liberated only by 
the disintegration of the diplococci. The serum not only destroys the diplo- 



Eecovered 


Died 


Per 


Ce 


107 


16 


16.5 " 


< i 


96 


30 


23.8 " 


a 


73 


39 


35. " 


( i 



638 MENINGITIS 

cocci but stimulates phagoc} r tosis and thereby causes the dead cocci to be 
quickly swallowed up by the leukocytes, wherein their intracellular poison is 
destroyed. The serum, therefore, acts directly by destroying the diplococci 
and indirectly by stimulating the leukocytes to destroy their toxins. Under 
the serum treatment the turbidity of the cerebrospinal fluid gradually disap- 
pears, and recovery, when it occurs, is more complete, the sequelae in these 
cases being comparatively rare. Deafness occurred in a few instances, and 
this was "the only persistent defect noted." The duration of the disease un- 
der the serum treatment was greatly shortened. The average duration of 228 
cases was eleven days. 

Symptomatic Treatment. — The pressure symptoms are somewhat re- 
lieved by the withdrawal of the cerebrospinal fluid; for this reason it is 
important to allow all of this fluid to escape that will. The dietetic 
treatment of these cases is most important, as emaciation and loss of 
strength are rapid. Easily digested food in concentrated form, and alcohol 
in the form of whiskey or brandy well diluted, should be given; in young 
infants the nutritional problem is very difficult. The patient's surround- 
ings should be as quiet as possible, and the room darkened so that he may 
not be irritated by noise and light. An ice-bag should be applied to the 
head if it does not worry the patient. Warm baths followed by gentle 
rubbing of the skin with alcohol may be of service in promoting the periph- 
eral circulation and preventing bedsores; these measures, however, can 
do more harm than good during the stage of acute hyperesthesia of the 
skin. Chloral and veronal may be used to produce sleep. In the milder 
cases the bromids, and in the more severe cases the opiates, may be called 
for. Opium should not be used unless it be necessary, but the severe pains 
and nervous irritability which are present in some cases may demand the 
hypodermic use of morphin; if so, the initial dose should be small, 1/20 
to 1/50 of a grain, and gradually increased, if necessary. Tincture of 
strophanthus or tincture of digitalis may be used to stimulate the heart's 
action, and collapse may be combated by the subcutaneous injection of 
normal salt solution or camphor dissolved in sterile olive oil. During the 
slow convalescence which occurs iodid of potassium may be given. Be- 
fore the days of serum treatment this drug was largely used and was 
believed to exercise a favorable influence in removing inflammatory exu- 
dates. 

PURULENT MENINGITIS 

The term 'purulent meningitis is used to include all forms of menin- 
gitis not produced by the tubercle bacillus or the diplococcus intracellularis 
(meningococcus). It is, therefore, from an etiological standpoint not a 
distinct disease, but a pathological condition which may be caused by a 
number of pathogenic microorganisms. The clinical picture produced in 
these cases, regardless of the specific etiological factor, is so similar that 
for clinical reasons one is perhaps justified in grouping these various forms 
of meningitis under the same clinical heading. The term "purulent," 



PURULENT MENINGITIS 639 

however, as applied to this group of cases is misleading, in that it implies 
that tuberculous and meningococcus meningitis are not purulent, while in 
both of these forms the formation of pus may be a part of the pathological 
process. 

The most common causes of purulent meningitis are the pneumococcus, 
the streptococcus pyogenes, the bacillus influenzae, the staphylococcus pyo- 
genes, the typhoid bacillus and the colon bacillus. Of these the pneumo- 
coccus is by far the most common. 

Symptomatology. — The onset and general symptomatology of purulent 
meningitis more closely resemble the meningococcus than the tuberculous 
form. Its symptoms are frequently masked by the primary disease of 
which it is a complication; this is especially true when it is secondary to 
pneumonia, erysipelas and septicemia. In these conditions a meningitis 
involving the convexity of the brain may develop without immediately 
adding to the existing symptom group, other than to increase the delirium 
and deepen the stupor into a coma. However, in the great majority of 
cases of purulent meningitis, the characteristic symptoms of meningitis, 
as previously detailed, are sudden in onset and violent in character. One 
usually sees a sudden rise of temperature, projectile vomiting, marked gen- 
eral irritation, convulsions, rigidity and retraction of the neck, photo- 
phobia, contracted and unequal pupils, rapid, and later irregular, pulse, 
irregular and sighing respirations, the tache cerebrate, Kernig's sign, loss 
of consciousness and profound coma; localized convulsions and contrac- 
tures may occur. The disease in the great majority of instances ends 
fatally within a week or ten days from the onset of the initial symptoms. 

Diagnosis.— The differential diagnosis of the various forms of purulent 
meningitis can be made only by a careful examination of the cerebrospinal 
fluid (see Tuberculous Meningitis). A careful examination of this fluid 
will almost invariably reveal the exciting cause, and, with the finding of 
the pneumococcus, the streptococcus, the bacillus influenzae, the staphylo- 
coccus, the typhoid or the colon bacillus, the differential diagnosis is 
definitely made. The differentiation of purulent meningitis from the com- 
mon tuberculous form of this disease, as based upon the clinical syn- 
dromes produced, has already been noted under Tuberculous Meningitis. 

Pneumococcus meningitis is by far the most common form of puru- 
lent meningitis and is perhaps always associated with a general pneumo- 
coccic infection, the pneumococci being present in the blood as well as in 
the cerebrospinal fluid. It is usually associated with pneumonia or bron- 
chitis. It is sudden in its onset, and, as a rule, runs a short and violent 
course, always terminating in death. The duration of the disease is com- 
monly from three to eight days. 

Streptococcus and staphylococcus meningitis may be rapid or 
gradual in their onset. They may occur as complications of erysipelas, sep- 
ticopyemia, middle-ear disease, mastoiditis, and fractures of the bones of 
the skull, as a complication in spina bifida and as a mixed infection in 
tuberculous meningitis. These cases run a somewhat less violent course 
42 



640 



MENINGITIS 



than the pneumococcic cases; the streptococcus form always terminates in 
death; the staphylococcus cases show a slight percentage of recoveries. 

Influenza meningitis is, as a rule, less sudden in its onset, but vio- 
lent and characteristic symptoms of meningitis soon develop, and the 
disease, in the great majority of cases, ends fatally. The percentage of 
recoveries here, however, is greater than in the preceding forms. 

Typhoid meningitis occurs as a complication of typhoid fever. It 
is commonly fatal, but less so than the other forms of purulent meningitis. 

Treatment. — Antimeningitis serum is of absolutely no value in the treat- 
ment of the forms of purulent meningitis above noted. In these cases, 
however, it is impossible to make a differential diagnosis of the exact type of 



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Fig. 97. — Typical Case of Pneumococcus Meningitis; Child Ten Years of Age. 



meningitis until a careful examination of the cerebrospinal fluid has been 
made. As this examination necessitates the loss of valuable time, and as 
the early administration of the antimeningitis serum is of so much im- 
portance in the meningococcic cases, it is perhaps advisable in all cases of 
purulent meningitis, where the diagnosis is in doubt, to inject into the 
spinal canal 30 c. c. of antimeningitis serum when the first lumbar 
puncture is made. If the examination of the fluid thus withdrawn shows 
the disease to be due to some other organism than the diplococcus intra- 
cellularis, the use of the antimeningitis serum is to be discontinued and the 
disease is to be treated symptomatically as outlined under Meningococcus 
Meningitis. 



ACUTE ANTERIOR POLIOMYELITIS 611 

Early and repeated lumbar puncture is advisable in all forms of menin- 
gitis. It relieves the pressure symptoms, and perhaps in the influenzal, 
typhoidal, and staphylococcus forms of meningitis it may increase the faint 
chances of recovery. 

Homologous vaccines, if given early, may be of value and should, there- 
fore, always be used in the staphylococcus form. 

The symptomatic treatment of purulent meningitis should include ab- 
solute rest and quiet in a well-ventilated room, careful and, if necessary, 
forced feeding, cathartic medication, ice-bags to the head, chloral and 
bromids to relieve nervous symptoms, and in some cases small doses of 
morphin hypodermically, to control pain and convulsions. If the inter- 
nal ear, the mastoid, or frontal sinuses are infected, surgical interference 
may be resorted to to drain these cavities, but it is questionable whether 
surgical measures of this kind are ever of any real advantage after the 
symptoms of meningitis have appeared. 



CHAPTER LXXX 
DISEASES OF THE SPINAL COED 

ACUTE ANTERIOR POLIOMYELITIS 

{Infantile Spinal Paralysis/ Polioencephalitis) 

Acute anterior poliomyelitis is an acute infectious, slightly contagious 
disease occurring both epidemically and sporadically. The inflammatory 
lesions begin in the meninges and spread to the cord, involving especially 
the gray matter of its anterior horns, but any portion of the central nerv- 
ous system may be involved. The symptom group produced will depend 
upon the extent of the anatomical lesions. In nearly all sporadic cases, 
and in the majority of cases occurring during epidemics, the clinical 
picture presented depends upon the involvement of the anterior horns and 
adjacent meninges of the cord, but in the epidemic form many cases occur 
presenting symptoms of acute polioencephalitis, bulbar paralysis or menin- 
gitis. 

Etiology. — The course and onset of this disease, the not uncommon oc- 
currence of a number of cases in the same family, and its appearance in 
epidemic form all point to the now generally accepted conclusion that it 
is caused by a specific microorganism, but as yet this microorganism has 
eluded the most careful search of bacteriologists. Landsteiner and Popper 
transmitted poliomyelitis to monkeys by inoculating them with an emulsion 
of the spinal cord, taken from a child just after death from this disease. 
Elexner and Lewis succeeded in carrying the strain of the virus thus ob- 
tained through many generations of monkeys. The virus is not destroyed 
by glycerination, will pass through the finest filters, is injured by heat, 
45° to 50°C, but is not destroyed by drying or by cold; it "belongs to the 



642 DISEASES OF THE SPINAL COED 

class of minute and filterable viruses that have not thus far been demon- 
strated under the microscope." The disease, may also be transmitted by 
the brain substance, lymph nodes, salivary glands, tonsils, mucous membrane 
of the nasopharynx, and by the blood and cerebrospinal fluid of monkeys ill 
of this disease. The experiments of many observers have demonstrated that 
the virus from the above-named sources will produce the disease in monkeys 
when injected into the brain, the spinal cord, the tissues adjacent to periph- 
eral nerves, the blood stream, and the anterior chamber of the eye, and 
also by rubbing the virus into the mucous membrane of the nasopharynx 
or introducing it into the stomach or intestines. These experiments sug- 
gest that infection in human beings may occur through the nasopharynx 
or gastrointestinal canal. The manner in which the virus may be trans- 
mitted from one individual to another is not known. In its epidemic form 
the disease extends through low-lying, well-watered areas and along routes 
of travel. It may be spread by abortive ambulant cases, by healthy interme- 
diate carriers, by animals having the disease, and perhaps by insects such 
as the common house-fly, and by fomites such as dust. 

Acute anterior poliomyelitis may occur sporadically or in epidemic 
form. The most notable epidemic in this country occurred in New York 
City and its surroundings in 1907; it included 2,500 cases. Holt and 
Bartlett made a very complete report on the "Epidemiology of Acute Polio- 
myelitis," which included an analysis of thirty-five epidemics. They found 
"many instances of closely connected groups of cases. In one instance 
there were seven in one family; in three instances four in a family; five 
instances of three in a family, and in all forty instances, comprising 69 
cases of more than one in a family." The startling increase in the epi- 
demic form of this disease is shown in Lovett's compilation of the reported 
epidemics since 1881 : 

Average 
Years. Cases. Outbreaks. Number of ^^ 

1880-1884 23 2 11.5 

1885-1889 93 7 13 

1890-1894 151 4 38 

1895-1899 345 23 15 

1900-1904 349 9 39 

1905-1909 8,054 25 322 

The sporadic form of this disease is rare during the first few months 
of life, but in the latter half of the first year it is quite common; the sec- 
ond year of life is the period of greatest susceptibility, and in the third 
year it is still quite frequent, but after the fifth year it is comparatively 
rare; about 50 per cent, occur during the first and second years, and 80 
per cent, during the first three years. 

The epidemic form occurs with almost equal frequency in young child- 
hood as in infancy; it is very common between the ages of four and thir- 
teen, and not uncommon in early adult life. This form is also slightly 
transmissible by direct contact; the degree of contagiousness is not very 



ACUTE ANTEEIOR POLIOMYELITIS 643 

great, since only a small proportion of exposed inclivi duals contract the 
disease. It occurs with slightly greater frequency in boys than in girls. 
Dry, warm weather very materially influences its spread. Fifty per cent, 
of the cases occur during the dry hot months of August and September, 
and 70 or 80 per cent, between the first of June and the first of October. 
Epidemics occur almost invariably during the warm, dry months, and are 
usually terminated by cold weather; occasionally, however, an epidemic 
is continued with sporadic outbreaks after cold weather has begun. 

Pathology. — Acute anterior poliomyelitis is a general infection produc- 
ing especially an interstitial inflammation characterized by congestion, 
perivascular round-celled infiltration and edema of the leptomeninges, the 
spinal cord and brain. Inflammatory changes occur first in the pia mater 
of the cord and the medulla, and are most marked around the blood vessels ; 
about these the round-celled infiltration is greatest and may contract their 
lumen, producing congestion, edema and minute hemorrhages. 

The cerebrospinal fluid is increased in quantity and quite early in the 
disease is opalescent, due chiefly to an increase in the number of lympho- 
cytes, although polymorphonuclear leukocytes may also be present. By 
the third or fourth day the cerebrospinal fluid is clear, but is still in- 
creased in quantity, and contains a large number of lymphocytes. 

All of the blood vessels of the cord coming from the inflamed pia are 
congested and show perivascular round-celled infiltration, and there results 
a more or less general myelitis, more marked in the gray matter of the 
anterior horns and commonly most severe in the cervical and lumbar en- 
largements than in other segments of the cord. This inflammation in 
the cord, like that in the meninges, is marked by congestion, round-celled 
infiltration, edema and minute hemorrhages, and results in extensive dam- 
age to nerve cells, especially the motor nerve cells in the anterior cornua. 
Ganglion cells, however, in the posterior horns, especially in Clark's col- 
umn, are not uncommonly affected. The degenerative changes in the 
nerve cells may result in their complete destruction, and a permanent mo- 
tor paralysis and atrophy of the muscles supplied by the axons coming 
from these cells. Edema, or temporary alteration leading to functional 
impairment, but stopping short of permanent degeneration of the ganglion 
cells, may cause a transient paralysis of the muscles innervated by their 
neurons. The predominance of these lesser lesions explains the fact that 
the greater part of the widespread paralysis occurring during acute an- 
terior poliomyelitis is transient, and also explains the hopeless character 
of the final permanent paralysis of an associated muscle group. 

It is important to remember that inflammatory lesions may also occur 
in the white matter of the cord, thereby implicating the long ascending 
and descending tracts, thus explaining such rare lasting motor disturb- 
ances as ataxia, exaggerated reflexes and muscular spasticity. Inflam- 
matory changes in the spinal ganglia, the medulla oblongata and pons 
varolii, similar to those above noted in the cord, may occur, and infiltra- 
tion around the deep nuclei of cranial nerves explains the facial and other 



644 DISEASES OF THE SPINAL COED 

paralyses of these nerves. Like changes may occur in the cerebellum 
and less rarely in the cerebral cortex. In fatal cases not only the pia 
mater and the spinal cord, but the medulla, pons, basal ganglia and even 
the cerebrum may be involved in the inflammation. In mild cases, espe- 
cially of the sporadic type, the inflammatory changes are almost or quite 
limited to the anterior half of the cord, and the paralysis which accom- 
panies and follows this condition is largely due to degenerative changes in 
the anterior horn cells of its cervical and lumbar enlargements. 

Chronic Changes. — As time goes on many of the injured ganglion 
cells entirely recover, others are destroyed, and the axons emanating from 
them disappear. The destruction of the nerve roots makes the anterior 
nerve root bundles smaller and produces an atrophy of the muscles, while 
the absence of the trophic influence of the anterior cornual cells is shown 
by more or less lack of development of that part of the body supplied by 
the diseased nerve cells. In such cases also the affected part of the cord 
is diminished in size and sclerotic changes occur. 

Lesions are found outside of the nervous system, but they are not 
characteristic. Bronchopneumonia and parenchymatous degeneration 
of the liver and kidneys occur. Changes in the mucous membrane 
of the small intestine and stomach are common; congestion and enlarge- 
ment of the solitary follicles, Peyer's patches and mesentery glands are 
common. 

Immunity. — One attack is believed to confer immunity. 

Symptomatology. — Wickman has described eight distinct types of acute 
anterior poliomyelitis, namely: the spinal poliomyelitic ; the abortive; the 
ascending or descending; the bulbar or pontine; the encephalitic ; the 
ataxic; the polyneuritic, and the meningeal. 

Spinal Poliomyelitic Type. — This is the ordinary form. Its onset 
is marked by nervous irritability, restlessness, headache, pain in the spine 
and extremities, fever, sweating, marked prostration, and gastrointestinal 
disturbances. Vomiting is common, diarrhea is present in about one-half 
the cases, and constipation in the remainder. Tonsillitis may also occur 
as an initial symptom. The fever in mild cases varies from 100° to 
101°F. ; in severe cases it may reach 105°F. It occurs as an early symp- 
tom and continues in mild cases for one or two days, and in severe cases 
for a week. Hyperesthesia is present, and movement of the body, especially 
the head, produces pain. The pain, tenderness, and rigidity of the muscles 
of the neck and spine are early and characteristic symptoms, usually asso- 
ciated with a slight retraction of the head. The mind is usually clear, 
but apathy and drowsiness may occur; very rarely delirium, convulsions, 
and coma are seen. Early, the deep reflexes are frequently exaggerated, 
but later they are diminished and vasomotor disturbances are very com- 
mon. Paresthesia or numbness may precede or accompany the beginning 
paralysis. Meningitic symptoms are present in some cases; with the pain, 
stiffness, and tenderness of the neck and spine there may be a marked re- 
traction of the head, intense nervous excitability, photophobia and a mod- 



ACUTE ANTERIOR POLIOMYELITIS 645 

ified Kernig's sign. The spleen is enlarged and leukopenia with a rela- 
tive increase of lymphocytes occurs early. 

The clinical syndrome made up in whole or part of the symptoms 
above noted may continue for four or five days, and then gradually sub- 
side, and during this time the characteristic paralysis makes its appear- 
ance. With the onset of this paralysis the pain, tenderness, and hyper- 
esthesia previously noted are increased in the paralyzed part, and, rarely, 
a marked line of tenderness may be noted along the peripheral nerves. 
In some cases, especially the sporadic ones, the fever and acute symptoms 
above detailed may be slight or absent, and the typical paralysis may de- 
velop with a few accompanying symptoms ; such cases are usually mild, and 
the paralysis is not widely distributed. 

Abortive Type. — During epidemics it is estimated by various observ- 
ers that from 15 to 50 per cent, of all cases belong to the so-called abor- 
tive type. They present a syndrome which commonly includes the follow- 
ing symptoms : fever, headache, nausea, vomiting, diarrhea, constipation, 
nervous irritability, pain in the neck, back and limbs, ataxia, diplopia, and 
exaggerated or diminished patellar reflex, but which may include any of 
the above-named symptoms associated with the ordinary form of this dis- 
ease. This symptom group, however, subsides into convalescence without 
a supervening paralysis, but these cases usually show extreme weariness and 
muscular weakness. Their diagnosis largely depends upon the fact that 
they occur during epidemics of acute anterior poliomyelitis and resemble 
in their onset, and in many of their symptoms, other cases of this disease 
having the supervening paralysis. The immune bodies which are present 
in the blood of patients recently recovered from frank attacks of this 
disease can also be demonstrated in the blood of these abortive cases by 
the fact that they render inactive the specific virus of this disease. 

The Ascending or Descending Type. — The clinical course of this 
type is identical with that of so-called Landry's paralysis. It may appear 
first in the lower or upper extremities or in the muscles supplied by the 
cranial nerves; it then descends or ascends. The ascending type is more 
common; it begins in the legs and may involve almost the entire body. 
As it progresses upward the muscles of the legs, abdomen, back, chest, arms, 
neck and diaphragm may be involved, and death commonly ensues from 
paralysis of the external muscles of respiration or from phrenic paralysis 
within from one to three days. This form must not be confused with that 
in which death results from paralysis of the centers of respiration. 

Bulbar or Pontine Type. — During epidemics, cases not infrequently 
occur in which the severe constitutional symptoms of acute polioencephalitis 
are associated with paralysis of the cranial nerves whose nuclei are situ- 
ated in the medulla oblongata and pons cerebri. The paralysis of these 
nerves may or may not be associated with paralysis of the trunk, neck or 
extremities. The facial paralysis in these cases is commonly unilateral 
and usually associated with an oculomotor paralysis, causing divergent 
squint with or without ptosis. Disturbances of deglutition, dyspnea, and 



646 



DISEASES OF THE SPINAL COED 



irregular respiratory action, with a rapid and irregular pulse, are common 
symptoms. The bulbopontine paralysis occurring in these cases may almost 
or quite disappear, leaving perhaps a slight facial or oculomotor paralysis. 
In severe cases obstinate constipation and retention of urine may occur, 
and death may result from splanchnic, cardiac, or respiratory paralysis. 

The Encephalitic Type. — This is characterized by symptoms re- 
sembling meningitis, and is associated with paralyses due to lesions in the 
motor areas of the brain, such as spastic monoplegia or hemiplegia, or to 
paralyses of the bulbar or pontine type. 

The Ataxic Type. — This is a polioencephalitis involving also the 
cerebellum. The symptoms, as in the encephalitic form, are very acute 
and violent, but the meningeal symptoms are associated with ataxia of 



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Fig. 



-Acute Anterior Poliomyelitis of the Bulbar or Pontine Type. 



In this case four doses of 16 ounces of normal salt solution, each containing 10 grains of 
urotropin, were given on the third and fourth day. After this treatment the child 
made a slow and complete recovery. 

movement of the arms and legs, nystagmus, and explosive syllabic speech; 
this form is very rare. 

The Polyneuritic Type. — In this type the peripheral nerves are in- 
volved, presenting a picture somewhat resembling multiple neuritis. It is 
not uncommonly associated with the ordinary spinal poliomyelitic type. 
Pain is the prominent symptom; it may be commonly elicited by pressure 
over the nerve trunks or joints of the paralyzed parts. In some cases the 
pain and tenderness are very marked in only slightly paralyzed parts, so that 
early in the disease the paralysis may be overlooked and a diagnosis of 
rheumatism or scurvy made. In other cases there may be a combination 
of flaccidity and spasticity, the latter resulting in contractures which may 
cause errors in diagnosis. 

The Meningeal Type. — This is an indistinct type, probably covered by 



ACUTE ANTERIOR POLIOMYELITIS 



647 



the encephalitic type above noted. It presents the symptoms of meningitis 
associated with paralyses of various kinds. 

Paralysis. — This is the characteristic symptom which confirms the 
diagnosis. During epidemics it may occur within the first twenty-four 
hours; in the sporadic form it is not, as a rule, recognized until much 
later, but in all cases, except those of the abortive type, it becomes so evi- 
dent between the second and the fifth day that it can scarcely be over- 
looked, even though it be overshadowed by violent acute symptoms. Ander- 
son & Frost say: "Cases of acute anterior poliomyelitis are encountered 
showing all gradations in the degree and extent of paralysis. In the same 
group may be found cases resulting 
in extensive and lasting paralysis; 
cases with permanent paralysis of 
slight extent ; cases in which the pa- 
tients have transient paralysis, re- 
covering completely within a few 
weeks or even a few days; other 
cases in which there is no definite 
paralysis, but merely muscular 
weakness of short duration; still 
others in which the only motor dis- 
turbance is ataxia, tremor or a tran- 
sient ocular disturbance, such as 
diplopia or nystagmus. Finally, 
within the same group are seen cases 
of illness exhibiting only the symp- 
toms of a general infection, usually 
accompanied by symptoms indicative 
of meningeal, spinal or encephalitic 
irritation, but without definite mo- 
tor disturbances." In the majority 
of instances the paralysis is motor 
and is complete and flaccid in char- 
acter; the part involved offers no 
resistance and falls limply into the 
position gravity directs. It reaches 

its maximum in from one to three days after its onset and involves the mus- 
cles of one or more limbs, and, more . rarely, the muscles of the trunk, 
neck and face. After a period of one or two weeks the paralysis be- 
gins to subside and the patient commences to regain motion in the 
paralyzed part. This improvement may continue rather rapidly for 
four or five weeks, leaving, in 90 per cent, of the cases, a group of 
muscles functionally related, still paralyzed. The extent of the re- 
maining paralysis represents the actual damage to the part involved and 
indicates the location and extent of the injury to the motor cells of the 
anterior horn or similar cells in the upper-lying parts of the nervous 




Fig. 99. — The Two Commonest Varieties 
of Foot Deformity from Anterior 
Poliomyelitis, in the Same Patient. 

In the right foot, equino-varus from paraly- 
sis of the peroneal group; in the left 
foot, valgus from paralysis of tibialis 
anticus and posticus. (A. Freiberg.) 



648 



DISEASES OF THE SPINAL COED 



system. After the third or fourth month the amount of improvement which 
occurs in the paralyzed member depends largely upon the treatment in- 
stituted, but, for the most part, the muscular paralysis then existing is 
permanent. In the great majority of cases the paralysis is confined to 
the lower extremities, and, as a rule, only one leg is involved. When the 
upper extremities are involved the paralysis is usually general, both arms 
and legs being affected, and the trunk and face muscles may also be in- 
volved. Less commonly one upper extremity is involved with one lower, 
usually on opposite sides, and still less frequently one upper and both lower 

extremities, and very 
rarely one upper ex- 
tremity alone is par- 
alyzed. 

In the rare cases, 
where the cerebrum 
as well as the spinal 
cord is involved, we 
may have a combina- 
tion of flaccid and 
spastic paralysis. 

Muscular atro- 
phy is one of the 
most notable features 
of this disease. Atro- 
phy and fatty degen- 
eration of the par- 
alyzed muscles and 
their tendons quick- 
ly begin, and become 
very marked after a 
few weeks. The wast- 
ing of muscles very 
materially re- 
duces the size of the 
affected limb. -In ex- 
treme cases the cir- 
cumference of the part may be reduced to almost half its original size ; this 
may in part be due to the loss of subcutaneous fat. The growth 
of the paralyzed limb is diminished so that in time it may be much 
shorter than its fellow. In severe cases the wasted, dwarfed and 
withered extremity is loose-jointed and markedly deformed. These de- 
formities result largely from the action of the normal muscles of the 
part, the antagonistic muscles being paralyzed. The foot, leg, hand, arm, 
and spine may thus be drawn into abnormal positions, resulting in various 
forms of clubfoot, clubhand, curvature of the spine and subluxation of 
joints, especially the shoulder and knee. The skin of the paralyzed part is 




Fig. 100. — Quadrupedal Gait in a Boy of Ten Years Re- 
sulting from Anterior Poliomyelitis. 

There was marked flexion contracture of the right hip and 
paralysis of the quardriceps extensor and sartorius of the 
right thigh. Extensive paralysis of leg muscles on both 
sides. Boy enabled to walk erect without crutches by 
means of tenotomies and tendon transplantation. (A. 
Freiberg.) 



ACUTE ANTEEIOK POLIOMYELITIS 



649 



notably reduced in temperature, it appears dry, shriveled, and at times 
cyanosed, and is cold and lifeless to the touch. A further evidence of the 
loss of the trophic influence of the anterior cornual cells is the great re- 
duction in the size of the bones of the affected extremities, as can be clearly 
shown by skiagraphs. 

The changed electrical reactions of the paralyzed muscles may be 
a very important diagnostic sign. They fail to respond to the faradic 
current, and, as the atrophy progresses, they show the reactions of de- 
generation to the galvanic current; that is to say, they respond feebly and 
slowly, and the anodal closure contraction exceeds the cathodal closure con- 
traction, and after a time they fail entirely to respond to any form of elec- 
trical stimulation. 

The reflexes in the paralyzed part are nearly always absent. The knee- 
jerk, however, may be present where the disease of the cord is confined 
to the cervical or lower dorsal region, and it may also be present in those 
cases seen during epidemics where the disease is confined to other portions 
of the central nervous system than the cord. 

Diagnosis The early. stage of acute anterior poliomyelitis so closely 

resembles that of other acute infections that it may be impossible to make 
a diagnosis until the paralysis is discovered. During an epidemic, how- 
ever, the physician should at least make a provisional diagnosis in the 
presence of the symptom groups which ordinarily announce the onset of 
this disease. It may be mistaken for acute intestinal infection or influ- 
enza, because of the presence of fever, vomiting, and nervous symptoms, 
but these disorders should soon be excluded by the subsequent course of 
the disease. When announced with high fever, general hyperesthesia, 
convulsions, and stupor, it may be mistaken for some form of meningitis; 
in such cases lumbar puncture may materially assist in clearing the diag- 
nosis, since a bacteriological examination of the cerebrospinal fluid fails to 
reveal the presence of microorganisms, but shows a large number of polynu- 
clear or mononuclear cells. In the early stages the blood may show a 
leukopenia and a moderate lymphocytosis, and Gay and Lucas note that the 
differential count shows a relative increase in the number of eosinophiles. 

With the onset of the paralysis there should be little difficulty in 
making a diagnosis if the following points pertaining to the differential 
diagnosis of the common paralyses of infancy, viz., infantile paralysis, 
cerebral palsy, and multiple neuritis, are kept in mind: 



Acute Anterior Poliomy- 
elitis 

Occurs most commonly dur- 
ing second year. 
Occurs sporadically and 
epidemically without ap- 
parent cause. 



Cerebral Palsy 

Occurs most commonly 
during first year. 
Usually due to cerebral 
hemorrhage or congenital 
defects, parturient inju- 
ries. 



Multiple Neuritis 

More common in child- 
hood and adult life. 
Follows diphtheria, rarely 
produced by other causes 
in childhood. 



650 



DISEASES OF THE SPINAL COED 



Acute Anterior Poliomy- 
elitis 
Convulsions, not commonly 
repeated, occur in 10 to 15 
per cent, of the cases. 
Paralysis (motor) com- 
plete, flaccid. Limb limp 
and non-resistant. 



Paralysis commonly eon- 
fined to one or both legs. 
Arms, trunk and back may 
be involved. 

Muscles atrophied and de- 
generated after a few 
weeks. 

Limbs shorter from lack 
of growth, a late symptom. 
Electrical reactions, al- 
tered and lost. 

Knee-jerk commonly lost. 

Intellect not involved. 



Cerebral Palsy 

Eepeated convulsions in 
most cases; frequently a 
causative factor. 
Paralysis (motor) partial, 
spastic. Limb rigid, con- 
tractures present. 



P a ra 1 y s i s, hemiplegic ; 
other forms such as diple- 
gia, paraplegia and mono- 
plegia comparatively rare. 
Muscles not atrophied. 



Lack of development, not 
so marked. 

Electrical reactions, nor- 
mal. 

Knee-jerk increased. Ba- 
binski sign, perhaps clonus. 
Lack of mental develop- 
ment. Epilepsy may result. 



Multiple Neuritis 
No convulsions. 



Paralysis (both motor and 
sensory) complete, flaccid. 
Limb limp, and may be 
acutely sensitive along the 
line of the nerve. 
Paralysis, paraplegic, or 
limited to the distribution 
of the nerves involved. 

Muscles slightly atrophied, 
but recover. 

No shortening. 

Electrical reactions, al- 

t e r e d and diminished, 

sometimes lost. 

General loss of reflexes in 

part involved. 

Central nervous system in 

no way involved. 



Prognosis. — Holt and Bartlett found in the epidemic form of this dis- 
ease a mortality of 12 per cent, in 1,659 cases. Wickman found the death 
rate under eleven years of age to be 12.2 per cent., and from twelve to 
thirty-two years of age 27.9 per cent. The Massachusetts State Board of 
Health found the mortality to be 16 per cent, in infants under one year; 
4 per cent, from one to ten years, and 20 per cent, in individuals over this 
age. In this type of the disease complete recovery without residual paraly- 
sis may occur in from 10 to 16 per cent. Death occurs most frequently 
during the first week, and commonly results from paralysis of respiration. 
In the sporadic form death is very rare, and complete recovery without 
sequelae is very uncommon. Within a few hours such destruction may be 
wrought among the anterior horn cells that the patient is more or less 
crippled for life. There is, however, no way of making an accurate prog- 
nosis from the early symptoms as to the amount of residual paralysis. The 
physician is therefore justified in being very guarded in his early prog- 
nosis. He may comfort the family by telling them that the intellectual 
development of the child will in no way be affected, but in predicting the 
amount of residual paralysis he should remember that there is a possibil- 
ity that the child may almost, if not completely, recover. After a month 
or six weeks the extent of the residual paralysis may be approximately 
estimated by the electrical reactions of the paralyzed muscles; those that 
fail to respond to any form of electrical stimulation will probably remain 
paralyzed. 



ACUTE ANTEKIOK POLIOMYELITIS 651 

The prognosis, so far as improving the function of the paralyzed part, 
is not altogether hopeless, even after the fourth month. Up to this time 
the improvement is progressive and spontaneous, but thereafter improve- 
ment depends upon securing the greatest possible functional development 
of those fibers in the paralyzed muscles which have not been hopelessly 
damaged, and on the education of adjacent muscles to the partial perform- 
ance of the functions of the paralyzed muscles. 

Prophylaxis. — These patients should be isolated and rigidly quaran- 
tined, and other members of the family should not be permitted to go to 
school, or to public gatherings. All members of the household, especially 
those who must necessarily come in contact with the patient, should use 
two or three times a day a nasal douche or spray of a 1 per cent, solution 
of peroxid of hydrogen, and they should be given urotropin in from 2- 
to 6-grain doses, according to their age, three times a day. The discharges 
from the throat, nose, kidneys and gastrointestinal canal of the patient 
should be disposed of in such a manner that his surroundings may not be 
infected, and that the common housefly or other insects may not carry con- 
tagion to other parts of the house. A rigid quarantine should be continued 
for three weeks, and house disinfection should then be resorted to, as de- 
tailed in the chapter on Scarlet Fever. Sprinkling of streets and lawns 
is also regarded as a wise prophylactic measure. 

Treatment. — General Treatment. — With the onset of acute symp- 
toms, cold applications to the spine are indicated, but in most cases the 
diagnosis is not made early enough to give the patient the benefit of this 
treatment. Absolute quiet and rest in bed should be insisted upon. Calo- 
mel in small doses followed by Eoehelle salts or castor oil should be given 
to move the bowels and control intestinal fermentation, and should be 
followed by liquid and easily digested food. Sedative medication to re- 
lieve nervous irritability and sleeplessness may be indicated; bromid of 
soda or phenacetin may be used for this purpose. Earely an opiate is 
necessary to allay pain. In severe cases associated with meningeal symp- 
toms, lumbar puncture may relieve the pressure and slightly modify the 
symptoms. In these cases hypodermoclysis with normal salt solution may 
be a life-saving measure. Strychnin and caffein-sodium-benzoate given 
hypodermically may be of value. Whiskey given by the mouth or by the 
rectum is valuable in all cases when, for any reason, sufficient food cannot 
be taken. 

There is no specific medical treatment for this disease, but animal 
experimentation indicates that hexamethylenamin (urotropin) should 
have some therapeutic value, not only as a prophylactic, but also as a cura- 
tive, remedy. My experience with this drug in the epidemic of this dis- 
ease which prevailed in Cincinnati in 1911 has led me to believe that it has 
some curative value if given early and in large doses. From the onset of the 
acute symptoms it should be given in from 3- to 10-grain doses, according 
to the age of the child, every four hours, and this dosage should be con- 
tinued only until the acute symptoms commence to abate. In one appar- 



652 DISEASES OF THE SPINAL COED 

ently desperate case in which the gastrointestinal symptoms were so vio- 
lent as to preclude all medication by month or rectnm for a period of 
four days, the child's life was saved by hypodermoclyses of physiological 
salt solution, to each of which was added 10 grains of urotropin. 

Treatment of the Paralysis. — When the acute symptoms have sub- 
sided and the child's life is no longer in danger, attention should at once 
be directed to the prevention of contractures and deformities in the par- 
alyzed parts. To accomplish this the paralyzed portion of the body should 
be maintained in as nearly a normal position as possible by the use of pil- 
lows, long bags of sawdust, or by light braces, or, if necessary, strapping 
with adhesive plaster. It is most important that during this early acute 
stage the paralyzed muscles and their tendons and the ligaments of the 
joints should not be stretched by allowing the paralyzed part to assume an 
unnatural position. Apart from this there is little to be done except to 
feed the patient carefully, give him plenty of fresh air, and shield him 
in every possible way from influences that might produce nervous irrita- 
tion. Above all it must be firmly impressed upon the parents and attend- 
ants that for at least two weeks, and possibly three, following the disap- 
pearance of acute symptoms, the paralyzed part is not to be exercised by 
massage, electricity, or in any other way. Then follows a long period 
during which electricity, massage, and active and passive exercise of the 
paralyzed part will be of great advantage. Electricity promotes the nutri- 
tion and keeps up the function of those muscles and muscle fibers which 
have not been wholly cut off from their communications with the cord. 
The faradic current may be used for those muscles which respond to its 
use ; other muscles more seriously affected may require the galvanic current 
to produce a contraction. The home application of the galvanic current, 
however, cannot, as a rule, be easily brought about, so that, in the great 
majority of instances, the faradic current alone is used, and this is sup- 
plemented by systematic massage. Massage, when administered by a skill- 
ful operator, exercises the wasted muscle, increases its circulation and 
promotes its nutrition, and is perhaps more generally applicable in pro- 
ducing these results than is electricity; it should be remembered, however, 
that in beginning this treatment the weak and wasted muscles require very 
gentle massage; strong massage may further weaken and injure them. As 
the child is brought gradually under treatment the most satisfactory re- 
sults are obtained by the daily use of mild systematic massage combined 
with the daily use of the faradic current, the one being given in the morn- 
ing and the other in the afternoon. This routine treatment may be con- 
tinued daily for three or four weeks, and then for a long period the mas- 
sage and electricity may be given on alternate days. As soon as the child 
has recovered sufficiently to use the paralyzed part great good may result 
from mechanical appliances properly adjusted by an orthopedic surgeon; 
great harm, however, may follow the unskillful use of heavy braces; the 
proper use of these appliances should assist the child in the voluntary use 
of weak muscles without aggravating the deformity, which has probably 



MYELITIS 653 

already resulted from the unbalanced contraction of muscles. In the late 
treatment of these cases certain operative measures are of value in reliev- 
ing deformities and improving muscular action. By lengthening, shorten- 
ing, anastomosing, or transplanting tendons, muscular action may be util- 
ized which was previously wasted, and loose joints may be made much more 
serviceable by fixing them by ankylosis. Muscle training is a very im- 
portant part of the treatment; it should accompany the massage after 
the third or fourth week of the child's illness, and should follow the opera- 
tive measures above referred to in the subacute and chronic cases. The 
patient, stripped and lying on a table, should be taught to make move- 
ments which will exercise and thereby develop partially wasted muscles; 
in the beginning it may be necessary for the instructor to assist the child 
in making these movements. Exercises of this character may be given for 
half an hour every day or every second day until the child is able to give 
up his braces. 

MYELITIS 

Myelitis is an inflammation of the spinal cord resulting in more or 
less disintegration of its tissues. The white matter may be indistin- 
guishable from the gray, and both may present the appearance of red 
softening. Capillary hemorrhages occur and the anterior horn cells of 
the affected areas are degenerated. If the destructive lesion be localized 
to a section of the cord, producing a more or less complete transverse 
myelitis, the sensory fibers of the posterior and cerebellar columns degen- 
erate upward and the motor fibers of the pyramidal tracts degenerate down- 
ward. The transverse forms of myelitis most frequently occur in the up- 
per half of the cord; the dorsal and cervical regions are favorite sites. In 
disseminated myelitis, resulting from syphilis and other causes, small areas 
of degeneration may be scattered throughout the cord. 

Etiology.—Myelitis is produced by bacterial infection. In childhood it 
occurs most commonly as a manifestation of syphilis, or as a complication 
of tuberculosis of the spine (Pott's disease) ; in this latter condition there 
is a preliminary compression followed by inflammation. It may occur as 
a sequel of one of the acute infectious diseases or as one of the manifesta- 
tions of a septic process located anywhere in the body. "Cold" and rheu- 
matism are classed among the exciting causes. Myelitis may result from 
the extension downward and inward of meningitis (meningomyelitis), 
and may be produced by injury to the spine, new growths pressing on the 
cord, and by spinal hemorrhage, but whatever may be the exciting factor 
the most destructive lesions are inflammatory and are produced by micro- 
organisms, most commonly streptococci and staphylococci. 

Symptomatology. — Transverse Form. — Fever and constitutional symp- 
toms exist in all forms of myelitis. They are much more marked, however, 
in the acute varieties due to infection. In these cases we may have a sud- 
den onset, temperature rising to 103° or 104° F., with more or less severe 



654 DISEASES OF THE SPIRAL CORD 

pain and tenderness over the spine, and within twenty-four or thirty-six 
hours the characteristic paralysis may begin to develop. These cases are 
in marked contrast to the much more common ones produced by Pott's 
disease and syphilis, in both of which the onset is insidious and the febrile 
reaction slight. 

To clearly understand the symptom group presented by myelitis, one 
should remember that the character and severity of the paralysis will de- 
pend upon the location and the severity of the lesion in the cord. In my- 
elitis one finds, as a rule, two distinct kinds of paralysis. In one part 
of the body the paralysis will be flaccid, having all the characteristics of 
this type as described under Acute Anterior Poliomyelitis. In another 
and lower part of the body the paralysis will be spastic, having all the 
characteristics of this type as described under Cerebral Palsies. Where 
the lesion is located in the cervical portion of the cord, the muscles of the 
arm which are directly innervated by the anterior cornual cells of this part 
of the cord will be in a state of flaccid paralysis, with loss of reflexes in 
the part, and sooner or later atrophy and the reaction of degeneration 
will be marked in the paralyzed muscles. All that part of the body below 
the lesion in the cervical cord will be in a state of spastic paralysis, which 
can be most easily recognized in the legs. The leg muscles may even be 
contractured, the reflexes are exaggerated, but there is no atrophy or 
reaction of degeneration in the paralyzed muscles. The spastic paralysis 
is due in these cases to the descending degeneration of the fibers of the 
pyramidal tract, which begins at the point of the cord lesion and extends 
downward. If the lesion be in the dorsal portion of the cord, as it com- 
monly is, the arms, and all of that part of the body above the lesion, will 
be free from paralysis, and the muscles of the trunk directly supplied by 
nerve fibers from the diseased portion of the cord will be in a state of 
flaccid paralysis, while the legs will be in a state of spastic paralysis. If 
the lumbar segment of the cord be involved in the myelitis, there will then 
be a flaccid paralysis of the lower extremities, with loss of knee-jerk and 
other reflexes, since the cells in the lumbar cord are in direct communica- 
tion with the muscles of the legs. In transverse myelitis the paralysis is 
symmetrical, bilateral, motor and sensory. The upper line of the paralysis 
is sharply limited by the lesion in the cord and is marked by a small zone 
of hyperesthesia, sometimes associated with a sensation of belt-like con- 
striction around the body. Immediately below this zone the various forms 
of sensation are almost or totally lost; complete anesthesia may exist. 

Vesical and rectal disturbances are among the characteristic symptoms 
of myelitis; the urine is retained and dribbles away from an overfull blad- 
der, and there is involuntary discharge of feces. The character, how- 
ever, of this disturbance of bladder and rectum differs with the localiza- 
tion. 

Bedsores very commonly develop, due to trophic disturbances of the 
skin, which make it possible for slight pressure and irritating discharges 
to produce extensive sloughing. It is a matter of the greatest difficulty 



MYELITIS 655 

in these eases to so care for the patient as to prevent the formation of 
bedsores. 

The above elinieal picture is that ordinarily presented by acute my- 
elitis of the transverse variety, but it should be remembered that it may be 
very greatly modified in individual eases, and the modification of the symp- 
toms will depend upon the location, character and extent of the lesions 
in the cord. 

Disszviixatzd Forms. — Tuberculous myelitis due to caries of the spine 
is the most common form of this disease in childhood : in the beginning it 
is purely a compression myelitis, and the paralysis develops very slowly. 
During this early stage the sharp lancinating pains radiating from the 
spine are due to compression of the nerve roots. This is an early and prom- 
inent symptom and is associated with marked tenderness over the spinous 
processes. The early paralysis that develops in these cases is spastic, tin- 
associated with the flaccid variety ; it occurs most commonly in the legs, but 
may occur in the arms. The reflexes are exaggerated, and hyperesthesia 
rather than anesthesia is present. As the inflammatory process invades 
the cord unilateral symptoms may appear, hut after a time these are re- 
placed by the symptom group above given of ordinary transverse myelitis. 

Syphilitic myelitis is slow and irregular in its onset; the paralysis may 
not he symmetrical, is never so well marked, and in this form of the 
disease the distribution of the paralysis, conforming above to the flaccid 
and below to the spastic type, is not seen. The morbid process is distrib- 
uted over a great portion of the cord and is not so intense at any one level. 
so that there may be great variations in the symptom group produced. 
Sensory paralysis may not always be associated with motor, and apparent 
recovery followed by relapses may occur. The irregularity of the symptom 
group in this form of the disease makes it necessary for one to depend 
largely upon other evidences of specific disease in making the diagnosis. 

Prognosis. — In compression myelitis due to Pott's disease the prog- 
nosis, so far as recovery from the paralysis is concerned, is rather favor- 
able if the diagnosis is made early and proper treatment is instituted 
before the cord has become infected: from 50 to 60 per cent, of these cases 
recover. In neglected cases, where infection of the cord has taken place 
and a complete transverse myelitis has resulted, the prognosis is bad. In 
syphilitic myelitis the prognosis is good if an early diagnosis is made and 
proper treatment is instituted. The symptoms, as a rule, yield to anti- 
syphilitic treatment. In syphilitic cases of long standing, however, while 
some improvement may follow the treatment, the prognosis, so far as 
ultimate recovery is concerned, is had. In acute infectious myelitis the prog- 
nosis will depend upon the location and severity of the lesion in the cord. 
The higher the lesion the greater the danger. The more destructive the 
lesion, as indicated by the severity of the symptoms, the more serious the 
prognosis. While on the whole the prognosis in severe lesions located 
high in the cord is bad. it is not wise to make an early unfavorable prog- 
nosis, since it is quite impossible for the physician to foretell with accuracy 
43 



656 DISEASES OF THE SPINAL COED 

the course that the disease will take in an individual case. One may gen- 
eralize and say, after observing the case for two weeks, that this being a 
mild case it will probably recover, or this being a severe one it will prob- 
ably die; yet it should always be remembered that in a few of the severe 
cases complete recovery takes place. In those cases in which the paralysis 
persists for months the great danger lies in the complications, such as bed- 
sores, cystitis and sepsis. These are important factors in producing a 
fatal termination in a large percentage of the subacute and chronic cases. 

Treatment. — Eest in bed under the most careful nursing, directed es- 
pecially toward the prevention of bedsores and cystitis, is a most impor- 
tant part of the treatment. The mattress upon which the patient rests 
should be most carefully selected with reference to conforming to the sur- 
face of his body without producing undue pressure at any point. Air and 
water mattresses are well adapted to this purpose. From the beginning 
the nurse should be carefully instructed to shift the patient, when awake, 
every hour or two, so as to avoid long pressure upon any one part of the 
skin. The skin should be rubbed with alcohol, and, if slight redness oc- 
curs, with zinc ointment, and at the first indication of a developing bed- 
sore all pressure should be removed from the part, and every effort made 
to restore the skin to its normal condition. The retention of urine, which 
occurs in this disease, necessitates the use of the catheter, so that it is most 
important in the beginning that the nurse should be carefully instructed 
to always use sterile catheters, anointed with sterile vaselin, for only in 
this way may cystitis be prevented. This complication is a much dreaded 
one, and, in the event that infection of the bladder occurs, it should be 
carefully washed out two or three times a day with an alkaline antiseptic 
solution. The dribbling of urine, which occurs in this disease, is a source 
of danger and irritation, and the patient should be protected from it, if 
possible, by the proper use of cotton. The nutrition of the patient must be 
carefully kept up throughout the whole course of the disease by a carefully 
selected diet, and attention to the digestive organs. Medication that inter- 
feres with the appetite or digestion will do more harm than good. 

In myelitis due to Pott's disease the aim of the physician should be to 
remove the pressure from the cord and cure the tuberculosis of the spine. 
To remove the pressure the patient should for a time be placed in bed 
and kept absolutely at rest. This is to be followed by a plaster-of-Paris 
jacket, so applied as to relieve the pressure on the cord and partially sep- 
arate and prevent the rubbing together of the diseased spinal vertebrae. 
With the jacket properly applied the patient can move and be moved 
without injury either to the cord or the spine. As the patient progresses 
the plaster jacket may be. replaced by a less cumbrous appliance in the 
form of braces, which will allow more freedom of motion and at the same 
time will protect the cord and firmly hold the spinal column until com- 
plete ankylosis of the diseased vertebras makes support no longer neces- 
sary. This part of the treatment should, if possible, be directed by an 
orthopedist. During all the time the above mechanical treatment is being 



HEREDITARY ATAXIA 657 

carried out the patient should be treated constitutionally as directed in 
the chapter on Tuberculosis. Without good food and fresh air a cure 
cannot be effected in these cases. 

Syphilitic myelitis is to be treated with mercury and the iodids as 
directed in the chapter on Syphilis. 

In acute infective myelitis the patient is to be put to bed as above 
directed. Ice may be applied intermittently to the spine during the first 
four or five days if it does not irritate the patient. As soon as the diag- 
nosis is made, 20 c. c. of antistreptococcic serum should be administered, 
and this dose is to be repeated every six to twelve hours until six doses 
have been given. Inunctions of unguentum Crede, 2 drachms every 
twelve hours, should also be used over the same period of time. This 
treatment may be of service in modifying the inflammation if the infection 
be streptococcic; in every instance where the myelitis follows one of the 
acute infections or appears without apparent cause it should be used. 

Residual paralysis and contractures are to be treated as recommended 
under Cerebral Palsies. 

In those cases that are fortunate enough to make a favorable conval- 
escence great care should be exercised in guarding them against the too 
early use of the muscles weakened by paralysis. These muscles require a 
long period of time to recover their normal strength and tone, and satisfac- 
tory convalescence may be interfered with by subjecting them to fatigue 
during this period. 

HEREDITARY ATAXIA 

(Friedreich's Disease) 

Hereditary ataxia is an hereditary disease of the spinal cord charac- 
terized by degeneration and sclerosis of the long posterior tracts, the cells 
of Clark and those of Gowers and their axons, and the spinocerebellar 
tracts. This is associated with a lack of development of other portions of 
the cord and of atrophy of its posterior roots. In addition the process fre- 
quently involves the lateral (pyramidal) tracts. 

Etiology. — Heredity is the most important etiological factor. It oc- 
curs as a family disease, extending through a number of generations. It 
is a disease of childhood, beginning, as a rule, before the tenth year of 
life. It may, however, occur in early infancy and in adult life. 

Symptomatology. — Ataxia is its characteristic symptom, and in many 
respects the symptoms resemble those of locomotor ataxia in the adult. 
In the beginning the child walks with his legs apart in an awkward, un- 
steady manner. The leg is lifted carefully and brought down suddenly 
as in locomotor ataxia. Romberg's sign is often present; that is to say, 
when standing still with the feet close together there is a swaying, un- 
certain movement of the body, and, if the eyes are closed, the patient falls 
to the floor. There may also be vibratory movements (choreiform) of the 
head and eyes. Later the ataxic movements become well marked in the 



658 DISEASES OF THE SPINAL COED 

arms ; these awkward, jerky, sudden movements of the arm may be brought 
about by asking the patient to pick up some object. Later on there is more 
or less rigidity of the muscles of the arms and legs which greatly interferes 
with the functions of these parts. Muscular power is gradually lost, so 
that late in the disease almost complete paralysis may result. The com- 
plete loss of the knee-jerk and other deep reflexes is an important symptom. 
Speech is slow, measured and difficult. In these cases the instep is highly 
arched, the toes hyperextended. Late in the disease the mind of the patient 
may be dulled and his expression stupid, though often the mental state 
remains unimpaired. 

Reflex pupillary rigidity (Argyll-Robertson phenomenon) and ocular 
muscle palsies do not belong to the picture of Friedreich's disease as they 
do to tabes. 

Prognosis. — This disease is invariably progressive. The patient in a 
few years becomes a hopeless cripple and perhaps an imbecile, unable to 
help himself in any way. These unfortunates often live far into adult 
life. 

Treatment. — There is absolutely no treatment that favorably influences 
the course of this disease. It becomes the duty, however, of the physician 
to prolong the lives and minister to the comfort of these unfortunate pa- 
tients. In seeking to accomplish these ends the diet may be carefully su- 
pervised, that it may serve nutritional purposes and come within the range 
of the child's digestive capacity. Outdoor life, wholesome, hygienic sur- 
roundings, and careful attention to the gastrointestinal canal are neces- 
sary. Orthopedic apparatus carefully designed to support weakened joints 
and prevent contractures may add to the comfort of the patient. 

SPINA BIFIDA 

This, the most common malformation of the central nervous system 
in infancy, is due to defective development of the vertebral canal. It 
usually consists in an absence of the spinous processes of one or more ver- 
tebrae; the laminae may also be absent. These defects open up the spinal 
canal, and through this opening its contents protrude, producing hernia 
of the spinal cord or its membranes, which is present at birth. This pro- 
trusion commonly occurs posteriorly in the median line and is usually 
located in the lumbar or sacral regions. In rare instances, however, the 
hernia may escape through a defect in the anterior portion of the spinal 
canal, producing a tumor, which protrudes into the lower abdominal or 
pelvic cavities. This latter condition is known as spina bifida anterior, or 
occulta. The following varieties of spina bifida are recognized: meningo- 
cele, meningomyelocele, and syringomyelocele. They are commonly asso- 
ciated with other congenital deformities. 

Meningocele. — Meningocele is the rarest and simplest form of spina 
bifida. It is a simple hernia of the membranes of the cord, which are 
pushed through the opening in the spinal canal by the fluid in the arach- 



SPIXA BIFIDA 



659 



noid cavity or subarachnoid space. The spinal marrow remains in posi- 
tion and the hernial tumor consists of spinal fluid, held by the globular 
dilatation of the skin and arachnoid. The dura mater opens posteriorly 
and becomes merged in the walls of the sac. The tumor is commonly lo- 
cated in the lower lumbar or sacral region, and may vary in diameter from 
2 to 6 inches. It is pedunculated, translucent and not associated with 
paralysis or any disturbance of the functions of the cord or nerves. The 
spinal defect in meningocele is commonly smaller than in the more serious 




Fig. 101. — Hydrencephalocele and Spina Bifida in an Infant One Day Old. 



forms of spina bifida; an X-ray picture, therefore, showing but a slight 
opening in the spinal canal, would indicate, in connection with the above 
symptom group, the presence of this form of spina bifida. 

Meningomyelocele. — This is by far the most common and most serious 
form of spina bifida. In this condition the accumulation of fluid in the 
anterior subarachnoid space pushes the spinal marrow and its posterior 
membranes backward through the opening in the spinal canal, producing 
a true hernia of the cord and its membranes. A cystic tumor is thus 
formed, containing the disintegrated and attenuated fibers of the spinal 
cord, which have been torn by the pressure of the fluid which carried it 



660 DISEASES OF THE SPINAL CORD 

into the sac. Remnants of the cord are blended with the inner layer of 
the sac, and, in some instances, so attached to its central wall as to pro- 
duce a restraining band, giving the tumor a slightly grooved or indented 
appearance, which is characteristic of this form of spina bifida. The 
tumor is located in the lower lumbar or upper sacral regions; it may vary 
from 1 to 4 inches in diameter ; it is translucent, but not, as a rule, pedun- 
culated. The most characteristic symptom of this form, however, is the 
paralysis, spastic or flaccid, of the lower extremities commonly associated 
with anesthesia and disturbances of the functions of the bladder or rectum. 
The skin covering the tumor may remain normal, but, more commonly, 
after a time, it becomes dark-red in color. In some instances the skin cov- 
ering is absent; in others it disappears under erosion from inflammatory 
processes; in these cases the thin wall of the sac may rupture, leading to 
infection of the cord and its membranes, which soon results in the death of 
the patient. 

Syringomyelocele.' — Syringomyelocele is a rare form of spinal hernia 
produced by an increased pressure of fluid in the central canal of the cord. 
This pressure results in pushing the posterior half of the cord and its 
covering membranes through the congenital opening in the spinal canal, 
producing a tumor so resembling meningomyelocele that it cannot with 
certainty be differentiated from it. In typical cases, however, of syringo- 
myelocele the paralysis of the lower extremities is sensory, the motor nerves 
not being markedly involved. It is commonly associated with hydro- 
cephalus, the dilated ventricle of the brain being in direct communication 
with the tumor through the central canal of the cord. 

Diagnosis. — While the differential diagnosis of meningomyelocele and 
of syringomyelocele is unimportant, it is of the greatest importance that 
these two conditions should be differentiated from the much rarer form 
of simple meningocele. The absence of paralysis and of other symptoms 
pointing to disturbance of the functions of the cord, with an X-ray picture 
showing but a small defect in the spinal column, would justify a diagnosis 
of meningocele and exclude the graver forms of spina bifida. 

Prognosis. — The prognosis in simple meningocele is favorable, but in 
the other forms in which the spinal marrow is involved the prognosis is 
very unfavorable. In many of these cases the sac ruptures during labor, 
or shortly after birth, and the septic infection of the cord and its mem- 
branes, which quickly supervenes, produces death. 

Treatment. — The treatment consists in protecting the tumor from fric- 
tion and other injury; this is a matter of no little difficulty. Bandages, 
holding soft compresses covering the tumor, may be worn. In selected 
cases the most satisfactory treatment is the removal of the tumor mass by 
a surgical operation. All cases of simple meningocele, and these are rare, 
should be referred to the surgeon for operation. All cases associated with 
marked paralysis or hydrocephalus are hopeless and cannot be benefited by 
surgical procedures. Operation, however, is to be recommended in all in- 
fants suffering from spina bifida who have lived to be 6 or 7 months of 



MULTIPLE NEUKITIS 661 

age, who have gained in "nutrition, and who, during this time, have shown 
satisfactory evidence of increasing mental development and who have either 
no paralysis or but slight paralysis of the lower extremities. Under no 
conditions should the operation for spina bifida be performed until the 
infant has shown satisfactory evidence of both mental and physical develop- 
ment, and this practically precludes operation until the child is 6 or 7 
months old. 



CHAPTER LXXXI 
DISEASES OF PERIPHERAL NERVES 

MULTIPLE NEURITIS 

Multiple neuritis is an inflammation of peripheral nerves, which re- 
sults in more or less complete loss of function to the nerves involved. It is 
usually symmetrical in its distribution. 

Etiology. — Diphtheria toxins are the most common cause of multiple 
neuritis in children. In the report of the collective investigation by the 
American Pediatric Society, paralysis occurred in 9.7 per cent, of 3,38^ 
cases of this disease which had been treated by antitoxin. It appears, 
therefore, that the antitoxin treatment of diphtheria, unless administered 
early, has little influence in preventing the subsequent development of 
neuritis. Influenza and malaria are perhaps the next most common causes 
of this disease in children, and, in rare instances, it may follow any of 
the acute infections. Alcohol and the metallic poisons, such as arsenic, 
lead, mercury and zinc, which so frequently produce this disease in the 
adult, are occasionally found as exciting factors in the child. Of this 
group of poisons Putnam finds that arsenic is the most common cause of 
neuritis in children. 

Pathology. — Neuritis may be either parenchymatous or interstitial. 
The parenchymatous form, which occurs in diphtheria, is the one usually 
seen in children. In this condition the evidences of the acute inflamma- 
tion of the nerve are absent, and in its stead there is a degenerative process 
which slowly destroys the axis cylinder and its myelin sheath; the neuri- 
lemma, or the sheath of Schwann, however, is left intact, and from the cells 
of this sheath the nerve may be regenerated and its function restored. In 
the interstitial form of this disease, which may be caused by the other 
acute infections, or by alcohol and the metallic poisons (lead excepted), 
there is also a degenerative process which may destroy the axis cylinder 
and the myelin sheath, but it is accompanied by an acute inflammation of 
the nerve, causing swelling, redness, tenderness, acute hyperemia, infiltra- 
tion with round or oval cells, and proliferation of connective tissue. The 
acute inflammatory process in the nerve, however, subsides early and the 
degenerative process proceeds to the more or less complete destruction of 
the nerve. In this form of neuritis regeneration and restoration of func- 



662 DISEASES OF PERIPHERAL NERVES 

tion of the nerve may also occur. But the regenerative process is slow, 
lasting over one or two months. 

Symptomatology. — The onset may be marked by fever, pain and gen- 
eral nervous irritability, but, as a rule, the paralysis develops insidiously, 
unannounced by acute symptoms. 

In diphtheritic neuritis the paralysis nearly always begins in the soft 
palate and pharynx. Attention is called to this fact by difficulty in swal- 
lowing, by the nasal twang of the voice and by regurgitation of fluid foods 
through the nose. Examination will show that the soft palate hangs down 
and does not rise in phonation. Usually there are anesthesia of the mucous 
membrane and an absence of the palatal reflex. The involvement, generally 
bilateral, is occasionally one-sided. Frequently there is involvement of the 
ocular muscles with palsies, and especially the ciliary muscle with loss of 
accommodation. Involvement of the adducens betrays itself by squint 
and the inability to turn the eye outward ; occasionally the vocal cords are 
paralyzed, resulting in hoarseness and aphonia. When these symptoms 
occur the knee-jerk should be carefully examined, as a diminution in this 
reflex indicates the extension of the paralysis to the lower extremities. 
The subsequent course of this paralysis is similar to that of multiple neu- 
ritis produced by other causes. 

The other forms commonly develop following one of the other acute 
infections, or perhaps without apparent cause. In these cases, without 
preliminary throat paralysis, the child commences to have an unsteady or 
ataxic gait, and fails to use its feet and hands in a proper manner; dur- 
ing this stage there may be muscular tremor and incoordination. The 
paralysis first becomes noticeable in the parts of the body most remote 
from the central nervous system; "wrist-drop" and "foot-drop" caused 
by paralysis of the extensors of the wrist and foot are early and character- 
istic symptoms. The paralysis may then gradually extend up the arms and 
legs; in severe cases it involves the muscles of the trunk and neck and 
produces complete general paralysis, the patient being unable to make a 
voluntary movement. He lies limp and helpless, and when the body is 
lifted the head falls about from lack of muscular support. Such wide- 
spread paralysis should always suggest multiple neuritis. The paralysis, 
however, is not, as a rule, so widely distributed, but, whatever may be the 
extent, it is symmetrical, and is associated with more or less sensory par- 
alysis. The sensory paralysis, however, is not, as a rule, complete, but 
partial anesthesia is common, especially during the early stages of the dis- 
ease. This complete, symmetrical motor paralysis, associated with disturb- 
ances of sensation, is the characteristic paralysis of this disease. In some 
cases, however, the sensory disturbances are not well marked, and, as a rule, 
they disappear long before the motor paralysis. Pain and tenderness along 
the course of the affected nerves are characteristic symptoms in nearly all 
forms of neuritis, except that produced by diphtheria; in this form they 
are absent. 

The nutritive function of the paralyzed nerve is also interfered with; 



MULTIPLE KEUBITIS 663 

this results in a mild form of muscular atrophy, nothing like so marked 
as that which occurs in anterior poliomyelitis. The reaction of degenera- 
tion is present in the atrophied muscles. The reaction to the galvanic cur- 
rent is slow and feeble, and the anodal closure contraction is greater than 
the cathodal closure contraction. In severe cases the muscle fails to re- 
spond to any form of electrical stimulation; in these cases the atrophy is 
more marked. The knee-jerk is commonly absent, and other reflexes of 
the paralyzed part are diminished or lost. 

Cardiac paralysis from involvement of the vagus and respiratory par- 
alysis from involvement of the phrenic and intercostal nerves may occur, 
but they are rarely seen except in the diphtheritic form of this disease. 
In cardiac paralysis there may be few or no warning symptoms and death 
may occur quite unexpectedly. In other cases the condition of the heart is 
made evident by an irregular, intermittent, weak pulse, and this may be 
associated with coldness of the extremities and precordial distress. In 
respiratory paralysis there is more or less disturbance of the respiratory 
rhythm with cyanosis and dyspnea, and as the diaphragm is commonly 
paralyzed, abdominal respiratory movements are absent; these symptoms 
are associated with great anxiety on the part of the patient. 

Diagnosis. — The differential diagnosis of multiple neuritis from other 
forms of paralysis in childhood is outlined under Anterior Poliomyelitis. 
Course.- — The paralysis usually increases in severity or remains station- 
ary for four or five weeks. Improvement then gradually sets in, from two 
to four months being required for the complete restoration of function. 
The great majority of these cases end in complete recovery; in some in- 
stances, however, a residual paralysis due to destruction of nerves and 
atrophy of muscles may occur. A fatal termination from cardiac and 
respiratory paralysis is rare, except in the diphtheritic form of this disease. 

Treatment. — Absolute rest in bed and freedom from conditions that 
produce nervous irritation should be insisted upon. Calomel followed by 
Eochelle salts or castor oil should begin the treatment. The dietetic treat- 
ment of these eases is important, since a disturbed gastrointestinal canal 
may greatly interfere with nutrition and unfavorably influence the prog- 
ress of the disease. A careful search in every case should be made for the 
cause of the disease. If metallic poisoning should be found, its source 
should be removed and eliminative treatment instituted. If malaria or 
syphilis be suspected, the specific treatment for these diseases should be 
given. In the great majority of cases the treatment should be mildly 
eliminative and otherwise symptomatic. The eliminative treatment con- 
sists in mild, warm alkaline baths, in the free use of water, and in keeping 
the excretory organs in good condition. One or two warm baths each day 
will not only promote elimination through the skin, but will greatly mod- 
ify the pain and discomfort from which these patients surfer. Drinking 
large quantities of water should also be insisted upon, as this is one of the 
most important therapeutic measures. Warm applications made with flan- 
nels or hop bags may modify the pain and tenderness along the nerves. 



664 DISEASES OF PERIPHERAL NERVES 

Phenacetin may be used to relieve pain, the bromids to overcome the gen- 
eral nervous irritability, and veronal to produce sleep. Opium is rarely, if 
ever, necessary, and should be avoided except in those cases where the pain 
is great and does not yield to simpler measures. The objection to opium 
is that it constipates and interferes with elimination and nutrition. Elec- 
tricity and general massage are of value late in the disease in keeping up 
the tone and nutrition of muscles and in bringing about an earlier restora- 
tion of function in the paralyzed parts. They are to be used as directed 
under Anterior Poliomyelitis. Strychnin, iron, cod-liver oil and other 
tonic treatment may be employed during the long period in which the 
restoration of function to the paralyzed muscle is being brought about. 
If cardiac and respiratory paralysis threaten, the patient should be kept 
absolutely quiet and not allowed to do for himself anything that can be 
done by others, and in the event that these dangerous symptoms commence 
to subside, the same absolute quiet should be insisted upon for a week or 
more after all symptoms of this character have disappeared. In such cases 
a fatal termination may sometimes be precipitated by rising up in bed. 
In cardiac failure strychnin and strophanthus are indicated; in respira- 
tory failure strychnin is perhaps the best remedy; these drugs should be 
given hypodermically. 

FACIAL PARALYSIS 

(Bell's Palsy) 

Etiology. — Facial paralysis is due to a paralysis of the seventh nerve. 
It may occur in the new-born from injury to this nerve by obstetrical for- 
ceps or from pressure of the face against the pelvic bones during protracted 
labor. 

In older children facial paralysis may be due to a peripheral neuritis 
of this nerve resulting from "cold." These cases are not fully under- 
stood and are usually spoken of as rheumatic, although there may be no 
other rheumatic symptoms present. This group includes all the idiopathic 
cases for which a definite exciting factor cannot be found; many of them 
are perhaps toxic in origin. Another group of cases are due to injury of 
the nerve from disease of the petrous portion of the temporal bone pro- 
duced by chronic otitis media or to injury from mastoid and other ear and 
face operations, or to parotitis and other inflammatory and traumatic con- 
ditions involving the tissues about the lobe of the ear. 

Intracranial lesions, such as tumors of the brain, basilar meningitis 
and fracture of the skull, may produce this same form of palsy without 
involving other nerves. 

Excluding the birth palsies the disease is very rare during infancy. 
In early childhood the ear cases are most commonly seen, and after the 
seventh year the idiopathic cases are most frequent. 

Symptomatology. — The palsy is purely a motor one; the sensory nerves 
are not involved; there are no pain or constitutional symptoms. The par- 



FACIAL PAEALYSIS 665 

alysis of the face is the only symptom, except in those cases that are due to 
internal ear or intracranial disease. In these cases the symptoms of the 
causative condition were present before the paralysis and continue after 
its development. There is a complete motor paralysis of the muscles of 
one side of the face, which produces a characteristic symptom group; the 
eye, as Bell noted, cannot be closed, efforts to accomplish this being asso- 
ciated with an upward movement of the eyeball; the face on the affected 
side is expressionless and attempts to move it produce grotesque expres- 
sions. There may be difficulty in talking, the child mouthing its words. 
Whistling, blowing, laughing, or opening the mouth develops a marked 
asymmetry in the two sides of the face; on the healthy side the angle of 
the mouth is drawn upward and the deep nasolabial fold is in contrast to 
the smooth face on the opposite side. In lifting the eyebrows, the forehead 
on the paralyzed side remains smooth in contrast with the wrinkling on 
the opposite side, and in attempts at showing the teeth the mouth assumes 
an irregular shape, the line between the upper and lower incisors, instead 
of being continuous, shows deviation. 

In those cases where the nerve is permanently injured atrophy of the 
muscles occurs. This leads to a wasting of one side of the face and to 
the development of the reaction of degeneration in the paralyzed muscles. 

Diagnosis. — From other forms of paralysis facial palsy can easily be dif- 
ferentiated by remembering that it is a motor nerve paralysis confined to 
the muscles of the face. There should be little difficulty in determining 
the cause of the facial palsy. Intracranial lesions, such as meningitis and 
brain tumors, announce their existence by characteristic symptoms. If 
facial paralysis be associated with deafness without apparent disease of 
the ear and weakness of the outward rotator of the eye, other symptoms 
of cerebellar tumor should be sought for. If a chronic otitis media exists 
it is probably the cause of the disease. In the absence of other causative 
factors it is assumed that the condition is due to cold or rheumatism (idio- 
pathic). 

Prognosis. — The prognosis will depend largely upon the causative con- 
dition. In birth palsies and in the idiopathic cases, due to "cold/' the 
prognosis is generally good; complete recovery occurs in from one to six 
months. The electrical reactions in these cases will materially assist in 
determining the course of the disease; if the muscles react to both the 
faradic and. galvanic currents in a normal manner at the end of the first 
week, recovery will be rapid, but if the muscles at this time fail to respond 
to the faradic current, but yet respond to the galvanic current, recovery 
may not be expected in less than two or three months. In the more se- 
vere cases, where the muscle not only fails to respond to the faradic cur- 
rent, but shows the reaction of degeneration to galvanism, and contracts 
but feebly and slowly to strong currents, the paralysis may continue for a 
year, and in some cases may be permanent. The prognosis in those cases 
associated with disease of the ear will depend altogether upon the charac- 
ter of the lesion. If the nerve be cut or otherwise destroyed, the paralysis 



666 DISEASES OF PERIPHERAL NERVES 

may be permanent, but, in the majority of cases, the injury to the nerve is 
of such a character that the removal of the exciting cause results in a slow 
but complete recovery. 

Treatment. — Cases due to disease of the ear or temporal bone require 
proper surgical treatment. Those occurring without apparent cause may 
be given salicylate of soda, as recommended in the chapter on Rheuma- 
tism; this treatment is especially indicated if the facial paralysis is asso- 
ciated with sore throat or pharyngitis. The salicylate treatment, however, 
should not be continued longer than three or four days, and is contrain- 
dicated if disease of the ear be present. Following this treatment the pa- 
tient's general health should be looked after by proper food, outdoor life 
and tonics. Iron, cod-liver oil and the malt preparations may be indicated. 
The most important part of the treatment, however, consists in keeping up 
the nutrition of the paralyzed muscles, and this should be done by massage 
and electricity, as directed under Anterior Poliomyelitis, but this treatment 
should not be begun until after the second or third week. In the use of 
galvanism, mild currents just strong enough to produce muscular contrac- 
tions should be used. 

Blisters and other forms of counter-irritation may be applied beneath 
the lobe of the ear; this is sometimes of value. In properly selected cases 
nerve transplantation may be of benefit. In this operation the facial 
nerve is cut and transplanted in the sheath of the hypoglossal nerve. Some 
good results have been reported from this operation. This surgical meas- 
ure is indicated only in those cases where the electrical reactions justify 
an unfavorable prognosis, or where the nerve has been cut in surgical 
operations. 

PROGRESSIVE MUSCULAR DYSTROPHY 

This term is used to embrace a group of syndromes characterized by 
more or less widespread atrophy and loss of function of the voluntary 
muscles. The atrophy is associated with fatty degeneration of muscle 
fibers and proliferation of connective tissue. In the pseudohypertrophic 
form the apparent increase in size of certain muscles is due to fatty de- 
posits; a true hypertrophy, however, of certain muscle fibers also occurs. 
In the peroneal type of this disease (if for convenience one may include it 
under this heading) the peripheral nerve changes discovered by Hoffman 
are believed to be the cause of muscular atrophy. In the other types no 
changes either in the peripheral or central nervous system have been found. 

Etiology.- — The causes of this disease are unknown. It is believed to 
be due largely to hereditary defects; at any rate it is distinctly hereditary, 
and, although boys are more commonly affected than girls, the hereditary 
transmission occurs almost always through the mother; a number of cases 
may occur in the same family. 

Symptomatology. — Pseudohypertrophic Form. — This is the most 
common of the clinical types of this affection. It develops, as do all the 



PROGRESSIVE MUSCULAR DYSTROPHY 



667 



others, slowly and insidiously, unmarked by acute constitutional symptoms. 
It begins, as a rule, between the second and seventh years of life, is char- 
acterized by progressive loss of strength in the voluntary muscles, the pa- 
tient becoming more and more helpless until he is hopelessly bedridden. 
But as the involuntary muscles are not involved and the vital organs are 
not affected, the patient may live many years, to die from some inter- 
current disease. 

The first symptom noticed is a clumsiness of gait associated with an 
increase in the size of the calf of the leg. There is a notable loss of power 
and endurance in the muscles of the lower extremities. As the disease 
progresses the hypertrophy of the calves is in contrast with the atrophy of 
the muscles of the thigh, back, shoulder, chest and upper arm. With the 
increasing atrophy there are gradual loss of power and final loss of func- 




Fig. 102. — Progressive Muscular Dystrophy, Pseudohypertrophic Form. 



tion on the part of the muscles. In the earlier stages, before the arm 
muscles are noticeably involved, the patient uses his hands to assist in 
making movements that are ordinarily accomplished by the now weakened 
muscles of the leg and back, and in doing so he assumes positions which 
are very characteristic of this disease. Some of these positions are illus- 
trated in the following series of photographs which represent different posi- 
tions assumed by the child in lifting himself from the floor. If placed 
on his back the patient slowly turns on his face, lifts himself upon his 
arms, and then, by the aid of his hands, "he climbs up himself until he 
finally reaches the upright position, and then, with legs widely separated, 
he walks with a clumsy waddling gait. The forward curvature of the 
spine, which increases with the wasting of the deep muscles of the back, 
is shown in the accompanying figures. The reflexes are diminished in the 
atrophied parts and the electrical reactions are feeble. As the disease 
progresses the patient finally becomes a helpless, bedridden invalid. Nystag- 



668 



DISEASES OF PEEIPHEEAL JSTEKVES 



mus, difficulty in speech, and lack of mental development may be present in 
these cases. 

Erp/s Juvenile Type. — This form usually occurs between the tenth 
and sixteenth year, and begins in the muscles surrounding the shoulder. 
They gradually lose their power, and may be wasted or hypertrophied. 
With the loss of function in these muscles the patient is unable to lift his 
arms, the atrophy extends to other muscles of the upper arm, back, thighs, 
and legs. With the atrophy and progressive loss of function of these muscles 
the patient gradually loses the power of locomotion, and becomes as help- 
less as in the pseudohypertrophic type. 

Landouzy-Dejerine Type. — This type, like the pseudohypertrophic 




Fig. 103.— Same as Fig. 102. 



type, begins in early life, but is differentiated from the others by the fact 
that the muscular atrophy begins in the face. It is first noticed about the 
mouth; the lips are thickened and everted, the mouth is slightly open, 
the patient being unable to close it. The muscles of the lower part of the 
face, neck and shoulder girdle, gradually become involved with a progressive 
muscular atrophy and loss of function. The subsequent history of these 
cases is similar to those of the Erb type. 

Peroneal Type. — This type of muscular atrophy is usually classed as 
a separate disease, since it is believed to be due to degenerative changes in 
the peripheral nerves. The atrophy begins in. the muscles of the feet and 
spreads to the muscles of the calf, producing a general atrophy, and in. 
time, complete loss of power of the muscles below the knee; the disease, 



DISOEDEES OF SLEEP 



GG9 



as a rule, is confined to this part of the body, but it may .spread to the 
thigh, hand, forearm and shoulder. 

Sensory changes in the atrophied part may be present, but total loss of 
sensation is uncommon. The reflexes below the knee and in other atrophied 
portions of the body are dimin- 
ished or lost. Although these pa- 
tients are hopelessly crippled, 
they may live for a long time. 
In those cases where the disease 
is limited to the legs below the 
knees the prognosis, so far as life 
is concerned, is especially good; 
in the other cases, however, where 
the disease extends to the thighs, 
arms, shoulders and other volun- 
tary muscles, the patients become 
hopelessly bedridden, and usually 
die from some intercurrent dis- 
ease. 

Treatment. — All of the above- 
named types are progressive and 
run their course uninfluenced by 
any kind of treatment. All the 
physician can do, therefore, is to 
treat them symptomatically and look to their general health. They should 
be carefully fed, live an outdoor life, and be placed under the best hygienic 
conditions. As long as they are able to use their muscles they should be 
allowed to do so. In accomplishing this end orthopedic appliances to over- 
come contractures and to support the spine, the ankles, and the knees may 
be of great service in keeping the patient on his feet for a longer time than 
would otherwise be possible. 

Massage, passive movements and electricity may be used to promote 
circulation and stimulate the nutrition of the slowly degenerating muscles. 




Fig. 104.— Same as Fig. 102. 



CHAPTEE LXXXII 
GENERAL NERVOUS DISEASES 

DISORDERS OF SLEEP 

Sleep is the physiological rest which the tired organism demands to 
repair the fatigue changes incident to the physiological activity of cells, 
especially those of the nervous and muscular systems. The physiological 
activity of all the organs of the body alternates with periods of relative 
repose. This repose is absolutely necessary to the vital activity of cells. 



670 GENERAL NERVOUS DISEASES 

In the higher animals the central nervous system rests at least once in 
twenty-four hours, and this condition of rest is called sleep. Normal sleep 
is characterized by loss of consciousness, loss of voluntary inhibitory con- 
trol of motor and mental acts, and more or less complete loss of all the 
special senses. Sight goes first, probably taste and smell next, and finally 
touch and hearing disappear as sleep becomes profound. During sleep all 
of the higher functions of the brain are held more or less in abeyance, 
and the involuntary inhibitory control of motor and mental acts is also 
partially lost. The discharge of nervous stimuli to all the organs of the 
body is greatly diminished, and, as a result, there are more or less relaxation 
of the muscular system, and a feebler functional activity of nearly all the 
important glands. 

During sleep, however, the capacity of the central nervous system to 
react to peripheral stimuli is not altogether lost. But the more profound 
the sleep the stronger must the peripheral stimulation be to make any im- 
pression upon the nerve centers. In the very beginning of sleep the nerv- 
ous system may respond very actively to slight external stimuli, producing 
muscular twitchings of the body, which may be severe enough to arouse 
the individual with the knowledge that this spasmodic contraction has oc- 
curred. These phenomena, however, are more likely to occur in highly 
nervous individuals, the nervousness being produced by unusual activity 
of the brain before going to bed, or by an excitable condition of the higher 
nerve centers produced by toxins. While this condition of increased reflex 
excitability at the beginning of sleep can scarcely be said to be physiologi- 
cal, yet it is made possible by the fact that the higher nerve centers, which 
exercise inhibitory control over the lower, are the first to lose their func- 
tions under the influence of sleep; and, as sleep becomes more and more 
profound, the entire nervous system gradually sinks into a condition of 
more or less complete repose, the motor centers at the base of the brain, 
and the reflex centers of the cord being the last to come under its sedative 
influence. When the entire nervous system has come under the influence of 
profound sleep, the reflex centers of the brain and cord are not so readily 
excited to action by peripheral stimuli as they are in the beginning of sleep, 
when the inhibitory centers are in repose, and the motor centers have not 
yet lost their normal excitability. During the first hour sleep becomes more 
and more profound. At the end of this time the higher nerve centers are 
very profoundly under its influence, and it requires comparatively power- 
ful stimuli to bring the individual back to consciousness. During the sec- 
ond hour sleep becomes gradually less profound, and from this time on a 
comparatively slight stimulus is sufficient to awaken the individual. The 
profound sleep of the first two hours has been likened to a condition of 
narcotism, which slowly passes off, leaving the individual still unconscious, 
but easily aroused. The lower motor centers of the brain and spinal cord 
maintain about the same degree of irritability from the beginning to the 
close of sleep. They are apparently not influenced, as the higher centers 
are, by the narcotism of the first and second hours of sleep. 



DISOEDEES OF SLEEP 671 

The healthy newly born infant sleeps nearly all of the time, at least 
twenty out of the twenty-four hours. During the first month the normal 
infant is awake about four hours in the twenty-four. From this time on 
the child requires slightly less sleep, so that at six or eight months he is 
sleeping sixteen hours in the twenty-four, and at the age of one year he 
sleeps from twelve to fourteen hours. During the first few days of life 
sleep is heavy, owing to the fact that the organs for receiving and carrying 
peripheral stimuli to the central nervous system are not yet fully developed. 
From this time on during the next month sleep becomes less profound, 
and from the end of the third month to the end of the second year sleep 
is not so deep as it is after the third or fourth year, when the heavy sleep 
of childhood is seen. It is at this time in the life of the individual that 
the profound narcotism of the early hours of sleep is most noticeable. 

The most common disorders of sleep are night-terrors, somnambulism, 
and insomnia. Of these the most important is night-terrors, or pavor noc- 
turnus. 

PAVOR NOCTURNUS 

Pavor nocturnus is a neurosis dependent upon an abnormally irritabk 
nervous system, easily excited by reflex stimuli having their origin in 
distant parts of the body, or in the cortical centers themselves. It is char- 
acterized by a night -terror which finds expression in the child's screaming 
or crying out in a panic of fright during sleep. 

Etiology. — Predisposing Causes. — Heredity is a very potent etiological 
factor. In the most severe cases there is commonly a well-marked neurotic 
family history, and such neuroses as epilepsy, hysteria, chorea, migraine and 
neurasthenia not uncommonly occur in the family histories. This strong 
hereditary taint predisposes these children to muscular twitchings, convul- 
sions and reflex neuroses of all kinds. The particular defect of the nerv- 
ous system which is inherited is a feeble inhibitory control of mental 
processes and motor acts. This may explain the relationship existing be- 
tween epilepsy, infantile eclampsia, and night-terrors, which appear to be 
present in some families. Beyond this there is perhaps no direct connec- 
tion between these neuroses. While a neurotic family history, resulting in 
an extremely irritable nervous system under feeble inhibitory control, is 
jjresent in many of the more severe cases of night-terrors, this factor is by 
no means so well marked in the milder types of this disorder. In some 
instances the excitable nervous system seems to be wholly dependent upon 
other factors entirely foreign to hereditary influences. 

Malnutrition is an important factor in developing irritability of the 
nervous system in young children, and the common causes of malnutrition, 
such as lymph-node tuberculosis, chronic diseases of the gastrointestinal 
tract, chronic malaria, hereditary syphilis, and rachitis, with improper food, 
impure air, and bad hygiene, may therefore be important predisposing fac- 
tors of night-terrors. 

Mental overwork and excitement, when coupled with physical in- 
44 



672 GENEEAL NERVOUS DISEASES 

feriority, are most potent factors in producing the highly irritable state 
of the nervous system which makes possible the development of this syn- 
drome. School life, with its mental grind, persistent excitation, close con- 
finement, and eye-strain, may be a factor in the development of night-ter- 
rors. 

Exciting Causes. — The normal irritability of the nervous system of 
the child, having been exaggerated by bad heredity, malnutrition, mental 
overwork, or nervous excitation, makes it possible for certain reflex ex- 
citing causes to develop an attack of night-terrors. The intestinal canal 
is one of the most important sources of this reflex irritation; undigested 
food, improper food, excess of food, intestinal worms, and intestinal fer- 
mentations, with the intestinal toxins which they produce, may all act 
either directly or indirectly as exciting factors. Adenoids, enlarged ton- 
sils, and nasal obstructions that interfere with normal breathing during 
sleep, may either act as reflex factors or they may act by producing a 
partial asphyxia, and thus excite an attack of night-terrors. 

In many cases, however, the reflex factors are absent, or perhaps it 
might be better to say are so slight that they cannot be readily discov- 
ered. In these cases the attack is apparently excited by a horrible dream, 
which has its origin either in some alarming occurrence of the previous 
day or in the overstimulation of the emotional centers by blood-curdling 
tales or exciting fairy stories. The nervous systems of extremely neurotic 
children may be so excited by punishment, by fits of anger, and by fright 
that they fall asleep with the incidents of the day still impressed upon 
their nervous systems, and, as a result, the cortical centers do not come 
profoundly under the reposeful influences of sleep, and in the paroxysm 
of night-terrors which supervenes, the horrible vision which presents itself 
to the child in his night-terror is but an exaggerated reflex of some mental 
impression which he received during the day. 

Symptomatology. — Silbermann divided night-terrors into two rather 
distinct clinical types, which for the most part have been recognized by 
recent writers. One of these he called Idiopathic Night-Terrors, and the 
other Symptomatic Night-Terrors. The idiopathic type is of central or 
cortical origin, and the symptomatic of peripheral origin. In the de- 
scription which follows, these two types will be recognized. 

NIGHT-TEBKORS 

Central or idiopathic night-terrors has for its most important etiologi- 
cal factor an extremely excitable nervous system under feeble inhibitory 
control, which has been inherited from neurotic parents. In the family 
history of these cases, hysteria, neurasthenia, and the convulsive neuroses, 
all of which are largely dependent upon feeble inhibition, are common. 
The inherited neurotic condition may also be aggravated by malnutrition 
and improper training. There can be little doubt, however, that even in 
these cases peripheral irritation plays a part in touching off the paroxysm ; 






DISORDERS OF SLEEP 673 

but the central nervous system is in such a state of excitability, and under 
such feeble inhibitory control, that a slight peripheral irritation produces 
a maximum result, and for these reasons it is commonly disregarded or 
overlooked. Idiopathic night-terrors occur in the great majority of in- 
stances between the ages of two and eight years. This is the period of 
life when feeble inhibitory control of cortical and other centers is respon- 
sible for many of the graver nervous diseases, such as eclampsia, epilepsy 
and chorea. 

The Paroxysm. — A neurotic child, with his nervous system unusually 
excited by the incidents of the day, falls asleep, and after an hour or two 
suddenly starts in his sleep with a cry of terror that alarms the household. 
A moment later he is found apparently wide awake, sitting up in bed, or 
crouching on the floor in a state of wild excitement, staring and pointing 
at some horrible, imaginary object which he seems to see with great dis- 
tinctness. He trembles with fear and gesticulates wildly, calling for as- 
sistance, but when spoken to fails to recognize his nurse, who is vainly 
endeavoring to arouse him to consciousness. He- may call out the name of 
some man or animal who he thinks is about to do him injury. After a few 
minutes of this agonizing fear the attack spends its force, the excitement 
gradually passes away, and the little patient falls back upon the pillow 
and becomes quiet in sleep, which may continue without further disturb- 
ance until morning. In many instances the child will go through an at- 
tack of this kind without recovering consciousness; in other words, the 
whole attack occurs during sleep. In other instances the strenuous efforts 
of the attendants may arouse the child to a vague consciousness, or, 
rather, semiconsciousness, during which, in a dazed way, he recognizes 
his surroundings, and then quickly drops asleep, and the next morning has 
little or no recollection of what has occurred during the night. According 
to Silbermann, Coutts, and other observers, the seeing of visions is the most 
characteristic feature of these attacks of central or idiopathic night-ter- 
rors. Similar attacks may occur for a number of nights in succession, or 
there may be an interval of weeks or months between them, but they al- 
ways present very much the same clinical picture, although they vary in 
intensity. 

Incontinence of urine may occur or the child may, at the close of the 
attack, make known his wants, and after seeking the commode pass urine 
or have a movement from the bowels, as though he were entirely conscious 
of his actions, and yet give no other evidence of being conscious of his 
surroundings. He returns to bed, continues his sleep, and the next morn- 
ing has no recollection of these occurrences. 

The central type of night-terrors is believed by many writers to be 
closely related to epilepsy, and quite a number of cases of epilepsy have 
been reported in which night -terrors occurred as a part of their early his- 
tory. Concerning this relationship, however, I am quite in accord with 
the opinion expressed by Charles Putnam in his excellent paper on this 
subject in the "Cyclopedia of the Diseases of Children." He says: "Al- 



674 GENERAL NERVOUS DISEASES 

together, the connection between night-terrors and epilepsy, in so far as 
they are separate diseases, is no clearer than that between any two of the 
neuroses, and yet, inasmuch as attacks closely resembling night-terrors are 
occasionally only symptoms of epilepsy, it is well to watch carefully for a 
time before deciding that epilepsy is not present." 

Symptomatic night-terrors are more common in childhood, but may oc- 
cur at any age, and are much more frequent than idiopathic night-terrors. 
In symptomatic or peripheral night-terrors the essential etiological fac- 
tor is outside the nervous system in some peripheral excitation. Children 
suffering from this symptom-complex have, as a rule, unstable and irri- 
table nervous systems, but this nervous instability, instead of being heredi- 
tary, is usually acquired. Chronic malnutrition and other factors capable 
of producing an unstable nervous system in an otherwise healthy child 
may commonly be observed. The reflex factors above noted as having 
their origin in the intestinal canal, nose, throat, and other organs are 
present, and can usually be very readily discovered. 

The Paroxysm. — The child falls asleep and may toss restlessly for an 
hour or two before the reflex irritation to the nervous centers culminates in 
an attack of night-terrors. The patient screams with terror, sits up in 
bed, or runs about the room. He is wildly excited, trembles with fear, and 
exhibits a very marked, but, as a rule, undefined, terror. He sees no visions 
and hears no noises, and responds to the efforts of his attendants to arouse 
him. He recognizes his attendants and seeks consolation from them. His 
nervous fears are soon quieted, and he falls asleep, to awaken the next 
morning with perhaps a vague recollection of the occurrences of the night. 

Clinical Pictures. — Silbermann, and after him Coutts, have called at- 
tention to the differences in the clinical pictures portrayed in the two types 
of night-terrors. Coutts uses the term nightmare to describe the class of 
cases which Silbermann speaks of as symptomatic or peripheral. As 
Coutts puts it, the chief distinction between these two symptom groups is 
that the one suffering from idiopathic night-terrors "sees visions/' while 
the one suffering from symptomatic night-terrors merely "dreams dreams." 
Silbermann expresses the same idea by saying that the former is charac- 
terized by objective terror and the latter by subjective terror. It may be 
added also that in the idiopathic form the terror is more real, the mental 
excitement greater, and the condition of unconsciousness more profound. 

Notwithstanding the differences in the clinical pictures which the two 
types of night-terrors present, I am not prepared to say that they are dis- 
tinct clinical entities. I am rather inclined to believe that the idiopathic 
type of this disorder presents the aggravated clinical picture as it may 
occur in highly neurotic children, whose mental and motor mechanisms are 
under feeble inhibitory control. Between this extreme type and the milder 
attacks of symptomatic night-terrors, due almost wholly to strong reflex 
excitation of an almost normal nervous system, there is indeed a wide dif- 
ference in the clinical pictures presented, but certainly not more so than 
there is in epilepsy or other neuroses. In this regard I quite agree with 



DISORDERS OF SLEEP 675 

Putnam, who says : "It is hard to convince one's self that there are two 
classes so definitely separated from each other. It is true that between two 
individual cases there may be a vast difference in all the particulars men- 
tioned by Silbermann, but, taking all cases together, the degrees of differ- 
ence are so slight that it is almost, or quite, impossible to draw a line of 
demarcation." 

Prognosis. — In the symptomatic form the prognosis is very good, be- 
cause it is produced by etiological factors which can readily be removed by 
appropriate treatment. In the idiopathic form the prognosis is not so good, 
and depends largely upon the gravity of the underlying hereditary taint. 
All of these cases, however, should yield to appropriate treatment, but 
idiopathic night-terrors should call attention to, and demand treatment for, 
the underlying hereditary condition. 

Treatment. — In beginning the treatment of all these cases the in- 
testinal canal must be carefully scrutinized and all possible reflex irrita- 
tion from this source removed. A preliminary cathartic followed by a 
carefully regulated diet with a light evening meal should be a part of the 
treatment in every case. It is impossible to lay too much stress upon the 
role which disorders of the gastrointestinal canal play in these cases. It 
is incumbent upon the physician, therefore, to thoroughly satisfy himself 
that the intestinal canal of the child is no longer a source of irritation or 
intoxication to the nervous system, and in doing this he must remember 
that intestinal toxemia may be present without any pronounced symptoms 
on the part of the gastrointestinal tract. Enlarged tonsils, adenoids, and 
nasal obstructions of all kinds, as well as all other discoverable causes of 
reflex irritation, should be removed. 

The child's general health should be carefully looked after. A diet 
should be selected with reference to the character of the malnutrition pres- 
ent. Tonics such as iron, arsenic, cod-liver oil, or malt containing diastase 
may be indicated in individual cases. An outdoor life, with an abundance 
of sunshine and fresh air, is also important. In the idiopathic cases the 
child's nervous system should be as carefully shielded from mental strain 
and nervous excitement as if it were suffering from one of the graver neu- 
roses. The medical treatment consists in giving the bromids of sodium, 
or potassium, in five- or ten-grain doses at bedtime. It is best to combine 
with this a dose of tincture of belladonna suitable to the age of the child 
(one to four minims). The bromid of potash, and belladonna will, as a 
rule, readily control the paroxysms, and, after four or five nights, all seda- 
tive medication may cease; in severe cases, however, it may be necessary 
to give this prescription for weeks at a time. 

INSOMNIA 

Prolonged insomnia, as it occurs in the adult, lasting through the 
greater portion of the night, is uncommon in children; when it does occur 
it is a symptom of some more or less serious disease. 



676 GENERAL NERVOUS DISEASES 

Disturbed or unrefreshing sleep, with possibly a few hours of wake- 
fulness, is common in childhood, and it is this condition, rather than true 
insomnia, which here interests us. 

Etiology. —Disturbed sleep is produced by very much the same etiologi- 
cal factors as night-terrors. A general nervous irritability is probably 
the most important underlying factor; it may be a matter of heredity, it 
may be produced by chronic malnutrition, it may occur in the convalescence 
from acute infections, and it may be very greatly exaggerated by more or 
less constant nervous excitement. The mental stimulation and strain of 
school life with night study, and the anxiety which sensitive children have 
concerning the lessons of the following day, may in older children be causes 
of disturbed sleep. In infancy nervous excitement is also a cause of rest- 
less sleep. The habit of constantly entertaining infants, and constantly 
attracting their attention, and bringing them into the whirl and excitement 
of the living-room, where they may be observed and commented upon, can- 
not be too severely condemned. Filling young minds with exciting stories 
before they are put to bed predisposes to dreams and disturbed sleep. 
Lack of proper training is, in the young infant, the most potent of all 
causes of insomnia. Rocking them to sleep, lifting and fondling them 
every time they make an outcry, and feeding them at night are causes 
which produce insomnia. Disturbances of digestion are important direct 
exciting causes. Overfeeding and improper feeding may develop in the in- 
testinal canal important reflex and toxic factors which, by their action on 
the nervous system, may disturb sleep. In infants intestinal fermentation 
may, by the development of gases, produce colic. This may also occur in 
older children, but, as a rule, constipation, with more or less obscure in- 
testinal toxemia, is with them d more important factor of nocturnal rest- 
lessness. In very young infants hunger may be a cause of sleeplessness. 
Poorly ventilated and overheated rooms, with lack of fresh air, heavy and 
uncomfortable bed-clothing, dentition, otitis, adenoids, enlarged tonsils, 
and nasal obstructions may cause restlessness at night. 

Varieties. — There are two rather distinct types of insomnia. In one 
the child retires, and, unlike the normal child, does not fall asleep prompt- 
ly. It rolls restlessly in bed,, very often is tormented by frequent desire to 
urinate, betrays its sensory irritability in this manner and also by its ex- 
treme sensitiveness to even the slightest noises, such as the ticking of a. 
clock, the creaking of the shutters, and the passing of the street cars. 
Finally, after two or three hours, it may fall asleep, but is usually a so- 
called "light" sleeper. 

In the other type sleep comes at once, but the child awakens in the 
middle of the night, and thereafter is unable to secure further sleep. Here, 
as in the first-named type, there will often be frequent micturition, flush- 
ing of the skin, aversion to much bed-covering, frequent punctilious ad- 
justment of the bed and pillows. Both types may exhibit a tendency to 
dreams, pleasant or unpleasant, as well as to recurring chains of thoughts 
peculiar to each individual. 



DISORDERS OF SLEEP 677 

It is unnecessary to state that such children do not awaken "re- 
freshed," but are prone to manifest the symptom-complex of abnormal 
fatigue. That the foundation for future neurasthenia is furnished by 
such prolonged sleeplessness goes without saying. 

Treatment. — The prophylactic treatment, which should begin when 
the child is born, is of the utmost importance. This consists in care- 
fully regulating the life of the infant, shielding it from excitement, feed- 
ing it at regular intervals, and insisting from the beginning that the night 
shall be devoted to sleep. It is a comparatively simple matter to establish 
a routine regularity which will firmly engraft upon the infant the habit 
of sleeping profoundly throughout the night. This habit, when once es- 
tablished and closely adhered to, will do much to overcome the nervous 
irritability which the infant may have inherited. As the child grows older 
this regularity in eating and sleeping should be carefully adhered to, and 
the child should be given a light evening meal and put to bed soon after- 
ward. 

Treatment of the Condition. — The treatment consists in attempting 
to establish the regularity, above referred to, with which the lack of proper 
training has interfered. An effort should be made to discover the essen- 
tial causes of the sleeplessness. Disturbances of the intestinal tract should 
be carefully treated, and all possible causes of reflex irritation, whether 
they occur in the nose, throat, or elsewhere, should be removed. The child 
should sleep in a well-ventilated and not overheated room, and the bed- 
clothing should be properly adjusted to the season of the year. If it surfers 
from cold feet, a warm bath at night with a hot-water bottle to the feet 
may assist in overcoming the sleeplessness. Shower baths are of great 
value ; in winter the hot and cold shower or spra}^ in summer a moderately 
cold shower. Overpressure at school and mental excitement of all kinds, 
especially just before going to bed, should be avoided. 

Insomnia, occurring as an acute condition in an otherwise healthy in- 
fant, should lead one to suspect acute intestinal disturbance. Intestinal 
pain produced by colic may be relieved by an enema, and the child that 
has fretted and tossed for hours may fall asleep. 

The use of medicines to promote sleep in children is rarely necessary, 
unless the restlessness is produced by some acute febrile condition. Bromids 
of potash and sodium are perhaps the most justifiable remedies under these 
conditions. Other hypnotics, which are so valuable in the treatment of 
insomnia in the adult, are of doubtful value in the child. 

SOMNAMBULISM 

Somnambulism, or sleep-walking, has very much the same etiological 
factors as night-terrors and insomnia. 

The somnambulist, soundly asleep and apparently unconscious, with 
his special senses in abeyance, may rise, walk, or run about in the dark, 
avoiding objects and performing difficult and apparently purposive acts 






678 GENEEAL NEEVOUS DISEASES 

quite as dextrously as he could when awake, but when aroused from this 
state he is unconscious of what has transpired. Somnambulism is not un- 
commonly observed in children, but the marvelously complicated movements 
which have been accredited to adult sleep-walkers have not been noted in 
the child. Children, however, may get out of bed and walk or run about 
the room in the pursuit of some object, or with a definite purpose suggested 
by a dream, which the child is acting. 

Sleep-talking may be combined with sleep-walking. I once witnessed 
a performance of this kind in a child seven years of age. This child during 
the day had been much interested in seeing his dog Towser catch and kill 
rats as they were one by one liberated from a trap. In the early hours of 
the night he sprang from bed and ran in the dark through the house, call- 
ing to his dog, "Eats, Towser, rats ! Towser, here they are !" and, for some 
minutes, avoiding furniture and directing his movements with great accu- 
racy, he led the chase until he was finally captured by his mother, and in 
his half-dazed state led back to bed and to sleep. The next morning he 
knew nothing of the occurrence. Earely somnambulism may be confounded 
with a graver type of automatic subconscious activity, the psychic equiva- 
lent of an epileptic attack. 

The treatment for this condition is the same as that above outlined 
for Insomnia. 

ECLAMPSIA IN INFANTS AND CHILDREN 

A convulsion is a sudden discharge of motor nerve force resulting in 
violent and rapid muscular contractions of one or more parts of the body. 
It is not a distinct disease, but a symptom group which may be produced by 
a great variety of causes. 

Etiology. — Predisposing Causes. — Age. — Infants during the first few 
weeks of life are comparatively immune to eclampsia, but from the fourth 
month to the end of the second year they are especially predisposed to all 
kinds of convulsive disorders. In the third year of life convulsions be- 
come less frequent, and from this time on in the normally developed child 
they are but slightly more common than they are in the adult. The ex- 
planation for the varying predisposition of the infant and young child 
to convulsive disorders at different periods of its life can be largely found 
in the anatomical and physiological development of the nervous system. 

The excitation of cerebral motor centers cannot readily produce con- 
vulsive disorders in the very young infant, because the discharge of nerve 
force from these centers is not readily communicated to the spinal reflex 
centers, since at this early period of life the fibers of the pyramidal tracts 
have not fully developed their myelin sheaths, and are not, therefore, ca- 
pable of readily transmitting impulses from the cortical centers to the 
spinal cells. The development of these myelin sheaths, however, gradu- 
ally goes on, so that the pyramidal tracts have their functions sufficiently 
developed to place the lower spinomuscular neurons and the cerebral mo- 



ECLAMPSIA, IN INFANTS AND CHILDEEN 679 

tor centers in close touch by the time the child is three or four months of 
age. In addition to this the following peculiarities of the nervous system 
of the young infant protect it to a certain degree from convulsive disor- 
ders: The cerebral motor areas at birth are but poorly developed and do 
not, therefore, readily react to excitation. These motor areas, however, 
are rapidly developed, so that early in the life of the infant they become 
very sensitive to all kinds of stimulation. The reflex centers in the spinal 
cord at birth are poorly developed and not easily excited, but these cen- 
ters also become very excitable after the third or fourth month of life. 
Both the sensory and motor peripheral nerves, which are a necessary part 
of the reflex arc through which convulsive disorders find expression, have 
a very low degree of irritability in the newly-born child. A little later in 
the life of the infant these nerves become hypersensitive. This hyper- 
excitability of peripheral nerves is much more marked in some children 
than in others, and constitutes the spasmophilic diathesis; spasmophilia is 
an important predisposing cause of eclampsia, tetany, and perhaps other 
convulsive disorders in infancy. 

The most important peculiarity of the young nervous system is the 
comparative lack of both automatic and voluntary inhibition, by reason of 
which higher nerve centers exercise little or no inhibitory control over 
the lower convulsive and reflex centers. Lack of inhibition is especially 
important, since it continues to a greater or less degree throughout infancy 
and young childhood; this explains the comparative frequency of convul- 
sions between the fourth month and the beginning of the third year, when 
both sensory and motor peripheral nerves are very excitable; the cerebral 
motor centers are very active and easily irritated; the spinal reflex centers 
are easily excited, and the communications through the pyramidal tracts 
between the cerebral motor centers and the spinal cord cells have become 
very close through the development of the myelin sheaths of the fibers of 
the pyramidal tracts. Later in the life of the child convulsive disorders 
are less common, because the spasmophilia has largely disappeared and 
the whole nervous system is now less irritable and more stable, and the 
inhibitory function of the cortical over the subcortical and lower spinal 
neurons is more firmly established. 

Heredity is a very important predisposing cause to convulsive disorders. 
Whole families of children will be found who have convulsions from very 
slight causes. The child may inherit, from neurotic ancestors, unstable 
and irritable nerve centers under feeble inhibitory control, which predis- 
pose it to all kinds of functional nervous diseases. 

Rachitis plays such an important role in the etiology of infantile con- 
vulsions that it is sometimes classed as a direct, rather than an exciting, 
cause. Eickets predisposes to neurotic disease in general and to convulsive 
disorders in particular, because it is the most common and the most pro- 
found form of malnutrition which occurs in infancy; it acts by exagger- 
ating all those physiological weaknesses of the nervous system of the in- 
fant, which may predispose it to convulsions, and as a result an infant 



680 



GENERAL NERVOUS DISEASES 



during the second six months of life, suffering from well-marked rickets, 
may have convulsions from causes so slight that they ofttimes cannot be 
detected. Other forms of malnutrition occurring during the convulsive 
age may predispose to eclampsia. Among these the following may he men- 
tioned : chronic gastroenteritis, hereditary syphilis, tuberculosis, scurvy, 
and anemia. 

Exciting Causes. — Intestinal toxins, usually of bacterial origin, are 
by far the most common exciting causes of convulsive disorders in infants 
under two years of age. Acute systemic intoxication, commonly of bac- 
terial origin, is the most frequent cause of convulsions after the second or 
third year. Many of the acute infectious diseases, such as pneumonia, scar- 
let fever, measles, poliomyelitis, cerebrospinal meningitis, smallpox, malaria 
and whooping-cough, may produce convulsions. Autointoxications of the 
recurrent vomiting type may rarely be ushered in by convulsions. Uremia 
is an important cause of convulsions, especially after the third or fourth 
year of life, and it should always be suspected if the child is suffering 
from or has recently had one of the acute infectious diseases, such as in- 
fluenza, scarlet fever or diphtheria. In every convulsive disorder the urine 
should be examined. Insolation is a not uncommon cause of convulsions 
in infants. The heat stroke probably acts by still further weakening the 
feeble inhibition of the infant. During the first days of life the most com- 
mon causes of convulsions are cerebral hemorrhage, asphyxia, and birth 
injuries to the skull and brain. 

Reflex Factoes. — While the importance of reflex irritation has been 
greatly exaggerated as an exciting cause of eclampsia, it should be noted 
that these factors are quite capable of producing a convulsive seizure in 
highly neurotic and rachitic infants having the spasmophilic diathesis. 
In many of these cases the predisposing causes are so potent that the ex- 
citing causes may be almost or quite overlooked. Undigested food, worms 
and other irritants in the intestinal canal, and perhaps even the cutting 
of a tooth, may, in highly predisposed infants, be the exciting cause of 
convulsions. In such cases, however, the exciting causes are so slight and 
the predisposing causes so powerful that the latter must oe considered as 
the important factors in producing the eclampsia. 

Epilepsy. — A symptom group characterized by recurring convulsions 
should be suspected when convulsions are repeated from time to time with- 
out apparent cause. Convulsions may be produced by organic lesions press- 
ing on or irritating the cerebral motor centers. Among such causes may 
be mentioned meningeal hemorrhage, meningitis, tumor, abscess, hydro- 
cephalus, embolism, thrombosis, and injury to the skull or brain. The 
role, however, which these organic lesions play in producing convulsions is 
slight as compared with the non-organic factors previously noted. 

Symptomatology.— Eclampsia is a syndrome and not a disease. This 
symptom group, however, always indicates the existence of some serious 
acute or chronic disease, the nature of which must be determined by other 
symptoms and by the general history of the case. 



ECLAMPSIA IN INFANTS AND CHILDREN 681 

Certain premonitory symptoms, such as sudden twitchings of the 
muscles of the arms, legs, or face, associated with high fever, may indicate 
that eclampsia is threatened. In many instances the physician will be 
called, not because the patient has fever or gastrointestinal disturbance, 
but because the mother has become alarmed at the occasional sudden jerk- 
ings or spasmodic contractions of the legs, arms, or face of her sleeping 
child. It may continue to toss restlessly in its sleep for a time, and then, 
without awakening, pass into a general convulsion. 

Perhaps in the majority of instances the convulsive storm occurs with- 
out warning. A sudden pallor of the face is followed by a convulsive 
stiffening of the muscles, the eyes roll up and become fixed, spasmodic con- 
tractions of muscles occur; these clonic contractions may almost imme- 
diately become tonic, producing rigidity of the entire body; the face is 
distorted, the head is drawn to one side, the hands are clinched upon the 
thumbs. Very shortly clonic convulsive jerkings of the head and extrem- 
ities supervene, and these severe spasmodic movements continue for three 
or four minutes, leaving the child relaxed, exhausted, and in a condition of 
more or less profound sleep, from which it may awake bright and conscious, 
or, without awakening, may pass into a second convulsion. The sleep which 
follows may be of short duration, or it may be a true stupor or coma which 
continues in the interval between the convulsions. The number of convul- 
sions in an individual case will depend upon the character and severity 
of the disease of which they are a symptom. There may be but one con- 
vulsion, or convulsions may be repeated at short intervals over a number 
of days. In the ordinary eclampsia of infancy the patient awakens from 
the sleep which follows the convulsion, appears bright, is conscious and 
gives little evidence of the severe nervous storm through which it has 
passed. In severe convulsive seizures incontinence of urine and feces may 
occur, and there may be more or less spasm of the respiratory muscles, pro- 
ducing a shallow, irregular breathing, or a spasmodic choking sound; cy- 
anosis may occur and life may be threatened by asphyxia. While uncon- 
sciousness and spasmodic muscular contractions are considered a neces- 
sary part of the eclamptic syndrome, these convulsive seizures may vary 
greatly in severity, from a momentary unconsciousness with slight twitching 
of some portion of the body to a general convulsion so severe as to take 
the life of the child. Convulsions may involve a portion of the body, or 
they may be general, or again they may begin in a certain group of muscles 
and spread until nearly the entire muscular system is involved. 

One attack of eclampsia does not necessarily predispose to another, un- 
less some organic injury to the nervous system results from the convulsive 
seizure. The same predisposing causes, however, which made possible the 
first convulsion may account for subsequent attacks from slight exciting 
causes. 

Prognosis. — Age is a very important factor in prognosis. In the new 
born the prognosis is bad, because convulsions at this time of life are com- 
monly produced by asphyxia, serious brain lesions, or congenital defects, 



682 GENEKAL NEEVOTJS DISEASES 

and are, therefore, frequently followed by spastic palsies, epilepsy, and 
mental defects. Convulsions occurring between the second week and fourth 
month of life, while they are not so ominous in their import as those oc- 
curring during the first week, yet they are, as a rule, more serious than 
those that occur between the fourth month and the end of the second year. 
At this latter period convulsions may occur from comparatively trivial and 
easily removable causes, and the prognosis is on the whole good. In older 
children, especially after the third or fourth year of life, the prognosis 
again becomes more grave, since convulsions at this time are commonly due 
to uremia or to one of the acute infectious diseases. Apart from the age of 
the child, the prognosis may be indicated by the severity of the initial con- 
vulsion; by the depth of the supervening coma; by the continuance of lo- 
calized contractures in the interval between the convulsions; by the fre- 
quent occurrence of convulsions without apparent exciting cause, by the 
evidence of some injury to the head, and by the presence of cyanosis, as- 
phyxia, and spasmodic breathing. It is well, however, for the physician to 
remember that even the above prognostic indications do not furnish safe 
grounds for a positive prognosis. One should, therefore, in all cases, give 
a guarded prognosis and await further developments to determine the 
causes which have produced the convulsion, since the character of the dis- 
ease which produces the eclampsia is the most important factor in prog- 
nosis. Pertussis and advanced rickets are among the etiological factors 
which add gravity to the prognosis. 

Treatment. — In the majority of instances convulsions are self-limited 
and last such a short time that when the physician reaches the patient 
the convulsive movements have ceased. The treatment in these milder cases 
from the beginning is directed to the prevention of subsequent attacks. 

In a small percentage of the cases, however, the convulsion itself is 
a source of danger not only to life but also to the subsequent well-being of 
the child, and the longer the convulsion lasts the greater are these dan- 
gers. In these cases the prime object in the treatment is to terminate the 
convulsion as soon as possible, regardless of its cause. This may be done 
by inhalations of chloroform ; the convulsive movements quickly cease when 
a few drops of chloroform are placed upon a handkerchief and held to 
the child's nose. The administration of chloroform may be repeated from 
time to time for the purpose of cutting short the return of convulsive 
movements, and this treatment may be safely continued until the convul- 
sive movements have been brought under control by other remedies. As 
soon as the convulsions have subsided under the inhalation of chloroform 
the child is placed in a bath, the temperature of which will depend upon 
a number of conditions. If the fever be high, one should begin with a luke- 
warm bath which is gradually cooled to 80° F. This not only reduces the 
body temperature, but exerts a soothing and tonic effect upon the nervous 
system. If, however, the patient be very young or very frail, the bath is 
not to be cooled below 90° or 95 °F. Immediately following the bath an 
ice-cap should be applied to the head ; it helps to keep down the tempera- 



ECLAMPSIA IN INFANTS AND CHILDEEN 683 

ture and acts as a sedative to the nervous system. The bath and ice-cap 
are to be used in the subsequent treatment of the case if high fever, convul- 
sions, and other nervous symptoms are present. 

A cathartic should be given as soon as possible regardless of the cause 
of the convulsion. The selection of the cathartic will depend upon the con- 
dition of the child's stomach. Castor oil is to be preferred if the stomach 
will retain it; a solution of Eochelle or Epsom salts may be substituted 
if the stomach be very irritable. If these be not retained, a quarter of a 
grain of calomel may be given every half hour until two grains are given. 
The importance of cathartic medication in the treatment of infantile con- 
vulsions does not depend wholly upon the fact that gastrointestinal tox- 
emia is commonly present, since even in those cases which have their origin 
entirely apart from the intestinal canal free catharsis quiets the nervous 
system and prepares the patient for any special dietetic treatment that 
may be necessary in the subsequent management of the case. A high rectal 
enema of a pint or more of physiological salt solution should be given im- 
mediately after removing the child from the bath. The object of this treat- 
ment is to unload and irrigate the large intestine, so as to remove any 
possible sources of irritation and prepare it to receive and retain sedative 
medicines which it may not be possible to give by the mouth. 

Chloral hydrate is the best and safest of all remedies to control con- 
vulsions; it should be given dissolved in starch water by high rectal enema 
half an hour after the colon has been unloaded by rectal irrigation. The 
dose per rectum for a child of six months is 5 grains and for a child of 
two years 10 grains ; if given by the mouth these doses are to be cut in half. 
It is wise not to risk upsetting the stomach either with food, stimulants or 
other medicines until the initial cathartic has been retained a sufficient 
length of time to insure its action. If the chloral is retained by rectum 
for three-quarters of an hour and the convulsive movements are under 
control, the physician may safely leave the case for the time being in the 
hands of a competent nurse with directions that the injection of chloral 
be repeated in one or two hours, and thereafter it should be given by the 
mouth in such doses and at such intervals as may be indicated by the age 
and condition of the child. After twenty-four hours the dose of chloral 
may be diminished in size and bromid of potash in 4- or 5-grain doses com- 
bined with it; the chloral and bromid treatment should be continued until 
all danger of convulsions has passed. 

Morphin is the most certain of all remedies for the control of convul- 
sions. A remedy like this, however, which acts so powerfully, should be 
used cautiously and in the proper dosage. If the chloral is not retained 
by the rectum, or if the convulsion be so severe that chloral fails to con- 
trol it, morphin should be given hypodermically, in doses varying from 
1/50 of a grain for a child six months of age to 1/20 of a grain for a 
child two years of age. As a rule only one dose of morphin is necessary, 
and thereafter the convulsive movements may be controlled by other rem- 
edies. If, in very severe eclampsia, which requires repeated doses of mor- 



684 



GENERAL NERVOUS DISEASES 



phin for the control of the convulsive symptoms, a prolonged period of 
coma or unconsciousness should follow, it is advisable to resort to venesec- 
tion followed by the injection into the vein or subcutaneous tissues of 6 or 
8 ounces of sterile normal salt solution, or Fischer's solution may be given 
intravenously as noted under Acute Nephritis. This treatment, especially 
in uremic poisoning, is frequently followed by a return of the child to 
consciousness. 

Absolute quiet for the nervous system and physiological rest for the 
gastrointestinal canal are necessary during the first few hours of treat- 
ment. Food and stimulants by the mouth should be avoided until the 
intestinal canal has been unloaded and the convulsive movements are under 
control. If, during this time, the child's condition demands stimulation, 
subcutaneous injections of normal salt solution (6 to 8 ounces) may be 
given at intervals of twelve hours. 

Following catharsis and the control of the convulsions, water, barley 
water and weak beef broth may be given by the mouth, provided the child 
craves food or drink. 

When the cause of the eclampsia has been ascertained, which may be 
from twelve to thirty-six hours after the onset of the first convulsion, the 
case is to be treated with reference to the control of the disease which 
caused the convulsions. If the trouble be of intestinal origin, as it com- 
monly is in children under two years of age, then the feeding should be 
that of Acute Gastroenteric Infection, which is elsewhere outlined. If 
the trouble be due to one of the acute infections, such as pneumonia or 
scarlet fever, the treatment for the underlying cause must follow. If 
nutritional disorders, such as acute rickets, be present, and the exciting 
cause of the convulsion is slight, the subsequent treatment must be di- 
rected toward the removal of the profound malnutrition, which is the 
important factor in producing the convulsion. If uremia or other forms 
of autointoxication be present, the proper treatment for these conditions 
must be promptly instituted. If the eclampsia be due to organic disease 
of the nervous system, the subsequent history of the case must determine 
the character of the treatment. 



LARYNGISMUS STRIDULUS 

(Cerebral Croup, Child Crowing, Inward Spasms, Laryngospasm) 

Laryngismus stridulus is a reflex neurosis due to an underlying pro- 
found malnutrition. It is most commonly observed in foundling hospitals 
and similar institutions for the care of infants. It is caused by a spasm 
of respiratory muscles and especially of the adductor muscles of the larynx, 
which results in a sudden closure of the glottis and a temporary shutting 
off of air from the lungs. 

Etiology. — Acute rickets is recognized as the most important etiologi- 
cal factor. Jacobi called attention to the relationship of craniotabes to 
this condition. Hereditary syphilis may also be an important factor. It 



LARYNGISMUS STRIDULUS 685 

occurs most commonly between the sixth and the eighteenth month, and is 
much more frequently observed during the months of January, February 
and March than other portions of the year. 

Stomach indigestion, enlarged cervical or bronchial lymph nodes, the 
dropping of mucus or other foreign substances into the larynx, fright, 
anger, acute adenoid and tonsillar disease, and perhaps even the cutting 
of a tooth, may be named among the reflex causes which are capable of 
touching off a laryngeal spasm in infants suffering from an advanced form 
of acute rickets, hereditary syphilis, or some other disease which produces 
a profound malnutrition and excessive irritability of the nervous system. 

Symptomatology. — A neurotic child suffering from one of the mal- 
nutritions previously named may, with little or no warning, be seized in 
the early hours of the night with a spasm of the glottis, which may com- 
pletely shut off inspiration. As the glottis is closing, the child sometimes 
in its struggles gives vent to a strident noise produced by the rushing 
in of air before the stricture of the glottis is complete. With the shutting 
off of air the child struggles for breath, its face becomes cyanotic, its head 
is thrown back, convulsive movements of the diaphragm occur, its body 
stiffens, and its life seems in imminent danger, when suddenly a loud 
crowing inspiration announces the fact that the spasm has relaxed and all 
immediate danger is over. It is the strident crowing sound that marks the 
close of the paroxysm which characterizes the symptom group and gives 
it its name. Following this strident inspiration the child breathes rap- 
idly, is greatly excited, cries and frets, and finally falls asleep, possibly 
to be awakened some hours later with a second attack. General convul- 
sions follow the laryngeal spasm in one-third of the cases. Convulsive 
movements of the diaphragm and other respiratory muscles are, as a rule, 
a part of the attack. Carpopedal spasm, which is one of the classical symp- 
toms of tetany, is present in one-half of the cases. 

Second and third attacks almost always occur within a few hours after 
the first attack, and, in severe cases, the child may have a dozen or more 
paroxysms in twenty-four hours. An attack of laryngismus stridulus may 
occur at any time during the day or night, but the first attack of the series 
most commonly occurs during the most profound sleep in the early hours 
of the night. 

Holding-tlie-breatli-spells which occur in older children are closely 
allied to, but not identical with, laryngismus stridulus. In this condition 
the spasm of the larynx is usually brought on by a fit of anger. Spasms 
of the larynx occur in acute laryngitis, whooping-cough and other diseases, 
but the clinical pictures produced are quite different from that of laryn- 
gismus stridulus. 

Prognosis. — The prognosis is good, so far as the paroxysm is concerned. 
If the underlying malnutrition can be successfully treated, then the progno- 
sis, so far as ultimate recovery is concerned, is also good. Some of the more 
severe cases die from asphyxia or general convulsions. 

Treatment. — Treatment of the Attack. — The child should be taken 



686 



GENEBAL NERVOUS DISEASES 



up; cold water dashed into its face, and a cold wet towel applied to its 
chest. If this does not relieve the paroxysm, chloroform may be given by 
inhalation. In more desperate cases intubation has apparently saved life. 

Prevention" of the Attack. — Following the initial attack the child 
for the first twenty-four hours should be kept somewhat under the influ- 
ence of chloral, 1 or 2 grains every two or three hours, according to its 
age. After the first twenty-four hours, bromid of soda or potash may be 
substituted for the chloral, 4 or 5 grains every four hours for a period of 
four or five days; in severe cases the bromid treatment may be continued 
for weeks at a time. 

Treatment of the Underlying Causative Condition. — This is all- 
important and should be followed up until complete recovery takes place; 
to accomplish this may require years. The special treatment indicated will 
depend entirely upon the character of the underlying malnutrition, 
whether this be rickets, syphilis, or tuberculosis; the treatment of these 
conditions is given in other chapters. The diet must be carefully selected 
to suit the age, digestive capacity and individual requirements of the pa- 
tient. The child should live in the open air and have as much sunlight 
as possible ; cod-liver oil and iron are important. When it has sufficiently 
recovered from its malnutrition, any disease of the nose or throat that may 
exist should be removed by appropriate medical or surgical treatment. 



TETANY IN INFANCY AND CHILDHOOD 



Tetany is a neurosis characterized by tonic contractures of muscles. 
These contractures may be intermittent, but, as a rule, they are persistent 
and subject to exacerbations at irregular intervals. The favorite site for 
these contractures is the extremities. The muscles of the trunk, neck and 
face may also be affected. 

Etiology. — Tetany occurs with far greater frequency in Europe than it 
does in America. In infancy males are slightly more commonly affected 
than females, the proportion being 5 to 4. Most of the cases occur during 
the winter and spring; this is perhaps due to the presence of rickets and 
other malnutritions at this period of the year. About 50 per cent, of re- 
ported cases are under two years of age. From this time on it occurs 
with decreasing frequency throughout childhood, but is seen again with 
greater frequency about the period of puberty; it may occur at any age. 

It is believed that some defect in parathyroid metabolism underlies 
many conditions characterized by muscle spasm. Attention has been called 
to a possible similar etiologic relationship in tetany, myotonia congenita, 
paramyotonia multiplex, and myokymia. 

Chronic gastrointestinal toxemia is perhaps the most important etiologi- 
cal factor; it is present in nearly every case occurring during the first 
two years of life. Eachitis is present in the majority of cases. The rickets 
associated with tetany, however, is not commonly of a very severe type, 



TETANY IN INFANCY AND CHILDHOOD 687 

and in this particular it differs from the rickets associated with laryngismus 
stridulus. Cases have been observed to follow measles, typhoid fever, 
rheumatism, and pertussis. 

Eeflex factors, such as undigested food, worms and foreign bodies in 
the intestinal canal, or adherent prepuce and adenoid growths, may be 
sufficient to excite a paroxysm of tetany in spasmophilic infants. The 
predisposing factors of tetany produce an irritability of the motor periph- 
eral nerves; this hyperexcitability of motor nerves constitutes in these in- 
fants the spasmophilic diathesis which makes it possible for slight exciting 
causes to produce exaggerated tonic contractions of the muscles which they 
supply. 

The pathological changes in the nervous system which are associated 
with the syndrome of tetany as it occurs in the young infant are not defi- 
nitely known. G. W. MacCallum and others have shown that tetany may 
follow extirpation of the parathyroid glands and that the symptoms in 
these cases may be controlled by the administration of calcium salts. It 
has been inferred from these facts that some defect in calcium metabolism 
may be etiologically related to tetany. In fatal cases hemorrhages into 
the parathyroids, hydrocephalus, hyperemia and edema of the brain and 
inflammation of the meninges and other lesions of the nervous system have 
been found. These changes are, however, inconstant and it is not believed, 
with the possible exception of the parathyroid findings, that they have any 
bearing on ordinary infantile tetany. Certain it is that, whatever may be 
the character of the changes underlying infantile tetany, they are, as a rule, 
temporary, since the great majority of cases terminate in complete recovery. 

The predisposing causes of infantile tetany, whatever they may be in 
an individual case, always cause, as Escherich and von Pirquet have dem- 
onstrated, a hypertonicity of the peripheral nerves, producing in them an 
abnormal excitability to the galvanic current which causes the muscle group 
supplied by the nerve to respond with both cathodal and anodal closing 
contractions to less than 5 milliamperes of current. The median nerve is 
usually selected for this test. This condition of peripheral nerve excita- 
bility to low galvanic currents is present not only in tetany, but in laryngis- 
mus stridulus, idiopathic convulsions in infancy- and other conditions char- 
acterized by muscle spasm. It is spoken of as the spasmophilic diathesis. 

In children suffering from the spasmophilic diathesis, attacks of tetany 
may be produced by such reflex factors as undigested food, worms, foreign 
bodies in the intestinal canal, adherent prepuce and adenoid growths or 
localized muscle spasm may be produced in them, as Erb, Chvostek and 
Trousseau long ago pointed out, by various forms of peripheral nerve irrita- 
tion. 

Symptomatology. — The most notable symptoms of tetany are tonic mus- 
cular contractures, which occur in almost any part of the body; the most 
common locations for these contractures are in the forearms, hands and 
feet, producing the carpopedal spasms. The positions assumed by the 
hands and feet are characteristic; the fingers are flexed at the metacarpo- 
45 



688 GENEEAL NEEVOUS DISEASES 

phalangeal joints, the phalanges are extended and the thumb is drawn 
across the palm of the hand. The wrist is sharply flexed on the arm, and 
the whole hand is drawn toward the ulnar side. In the more severe cases 
the forearms are flexed on the arms and pressed against the sides of the 
thorax. In moving the elbow the resistance is not so great, or so painful, 
as in moving the wrist. In milder cases the shoulder and elbow joints 
are freely movable, while the contractures of the wrist and hand are very 
strong. The pedal spasm usually accompanies the carpospasm and the con- 
tractures are usually symmetrical; the feet are extended, and the first 
phalanges of the toes are flexed, the others extended. The foot is curved 
inward and the tendo Achilles is very tense. The knee and hip joints are 
usually freely movable ; in some cases the thighs are adducted. While these 
contractures are commonly confined to the forearm, hands, and feet, it is 
not uncommon, in more severe cases, especially those under one year of 
age, to have contractures of muscles of the trunk and neck, producing 
opisthotonos and stiffening of the body. I have seen cases of this kind in 
which the infant's body remained rigid when lifted from the bed. In rare 
instances the muscles of the face and eyes are involved. 

A paroxysm of tetany may continue for a few days, or it may last for 
weeks, and during this time the muscular contractures are, as a rule, con- 
tinuous. There may, however, be periods in which there is a marked remis- 
sion, or even a short intermission of the spasm. When the paroxysm has 
subsided, the child, under proper treatment, as a rule, progresses slowly to 
a satisfactory recovery. Eelapses, however, may occur at variable inter- 
vals, weeks or months intervening. 

Pain usually accompanies the spasm; in bad cases this may be severe 
enough to cause the child to cry out. Pain is greatly increased by any at- 
tempt to move the contractured part, or by stretching or pressing on the 
contractured muscle. There is no loss of consciousness in this disease, 
unless general convulsions supervene; this complication is much less com- 
mon in tetany than it is in laryngismus stridulus. Edema of the feet, 
ankles and wrists may be present. 

The increased nerve and muscle irritability finds expression in increased 
electrical excitability of both nerves and muscles with changes in their 
qualitative reaction to galvanism (Erb), (neurotonic reaction). It is also 
shown in the facial phenomena known as "Chvostek's symptom/' in which 
spasm of the facial muscles is produced by percussing over the facial 
nerve, and in "Trousseau's symptom," where spasm of the feet and hands 
is greatly exaggerated by pressure upon the large nerve trunks leading to 
these extremities; also Hoffman's sign, an increased mechanical and elec- 
trical excitation of the sensory nerves. These phenomena, due to increased 
excitability of the peripheral nerves, may be observed not only during the 
acute paroxysm, but may be also elicited in many cases for some time after 
the muscular contractures have disappeared. So long, therefore, as Erb's, 
Trousseau's, Chvostek's and Hoffman's phenomena can be elicited, the pa- 
tient is not to be considered as thoroughly convalescent from the attack. 



NYSTAGMUS 689 

The danger of second and third attacks or relapses is not removed until 
the underlying intestinal disease and malnutrition have been cured. 

An elevation of temperature of two or three degrees is almost always 
present. This is perhaps due in part to the underlying toxemia. When 
the intestinal canal has been unloaded and careful feeding instituted, the 
temperature may fall to normal and remain so, even though symptoms of 
tetany may remain. 

Differential Diagnosis. — Tetany is to be differentiated from tetanus by 
the locations of the contractures and by their intermittency, and especially 
by the absence of trismus. Trousseau's, Erb's, and Chvostek's symptoms 
are absent in tetanus. The age, previous history and general condition of 
the child will materially assist in the differential diagnosis. 

Treatment. — Calomel followed by castor oil will serve the purpose of 
removing irritating and poisonous materials from the intestine and will pre- 
pare the patient for the very careful dietetic treatment that is to follow. 
The child must be fed with a view not only to correcting the existing mal- 
nutrition, but also to preventing further intestinal intoxication. This 
should be done along the lines detailed in the chapter on Chronic In- 
testinal Indigestion. For the control of the spasm, chloral and bromids 
may be used in moderate doses. Lukewarm baths, two or three times a 
day, will not only help in the relief of the spasm, but will benefit the in- 
testinal condition. The child should be given sunlight and fresh air; 
these are almost as necessary in the treatment of tetany as they are in 
tuberculosis. The patient should be kept as quiet as possible and protected 
from noises and reflex causes of irritation. As the child improves, cod-liver 
oil and iron are of great value in overcoming the malnutrition. A careful 
search should also be made for every possible cause of reflex irritation. The 
prepuce and rectum should be examined, and, as the child convalesces, the 
throat and nose should be inspected. The removal of reflex factors may 
facilitate recovery. Calcium lactate in 3- to 5-grain doses may be tried if 
the tetany does not yield in a few days to the dietetic treatment above 
outlined. 

NYSTAGMUS AND ASSOCIATED MOVEMENTS OF THE HEAD 

IN INFANTS 

W. B. Hadden, under the title, "Head-nodding and Head- jerking in 
Children, Commonly Associated with Nystagmus," described a not uncom- 
mon neurosis characterized by rotary, lateral, or vertical movements of 
the head, usually associated with rotary, lateral, or vertical movements of 
the eyes. 

Character of the Movements. — Peterson described, under the term 
"gyrospasms," a rotary movement of the head from right to left and left 
to right. These head movements may also take the form of "head-nod- 
ding"; in these cases the head moves with a vertical nodding motion. In 
other cases the movements of the head are horizontal. These vibratory 



690 GENERAL NERVOUS DISEASES 

movements are, as a rule, rhythmical and rapid, two or three vibrations oc- 
curring to the second. The same movements, however, do not always per- 
sist; any one may be replaced by or alternate with either of the others, 
or the three movements of the head, vertical, horizontal, and rotary, may 
all occur at different times in the same patient. Hadden says that pure 
nodding is rare, but this movement is commonly combined with or alter- 
nates with the lateral or rotary movements. In some cases these movements 
may cease when the child's attention is firmly fixed on some object, but, 
as a rule, they are increased when the child is under observation. During 
sleep the movements cease, and they are not so well marked and commonly 
disappear when the child is lying down and quiet in a darkened room, and 
they may sometimes cease when the eyes are covered. 

Nystagmus is commonly associated with these head movements ; the eye 
movements may be rotary, vertical, or lateral. The movements of the 
eyes, however, are more rapid than the movements of the head, the vibra- 
tions in some instances being as rapid as six to the second. These invol- 
untary vibrations of the eye are, as a rule, rhythmical. The horizontal 
movement is the most common, but it may alternate with, or be replaced 
by, vertical or rotary movements, and, rarely, according to Mills, "the 
vertical and horizontal oscillations may alternate regularly or irregularly, 
or a vertical movement may be present in one eye and a horizontal in 
another. The commonest form of nystagmus is that in which the move- 
ment is bilateral, horizontal, and consentaneous." 

The movements of the head and eyes do not always correspond. Any 
form of eye movement may be combined with any form of head movement ; 
for example, head-nodding may be combined with lateral nystagmus, or we 
may have nystagmus of one eye associated with any form of head move- 
ment. In short, any number of combinations of the various head move- 
ments and eye movements are possible, but it should be remembered that 
in perhaps a majority of cases the head and eyes move in the same direc- 
tion. The various head movements above described, while commonly asso- 
ciated with nystagmus, may occur without the nystagmus, and, on the 
other hand, the nystagmus may occur without the head movements. 

Etiology. — This syndrome usually occurs during the first year of life, 
commonly between the second and twelfth months. During the second year 
of life it is not infrequent, but after that it is very uncommon, except as 
it is associated with ocular defects, organic disease of the nervous system, 
insanity, or congenital idiocy. In this chapter, however, we are interested 
only in this syndrome as a manifestation of a not uncommon neurosis, 
which occurs almost exclusively between the beginning of the third and 
the end of the twentieth month of life. 

Heredity is an important predisposing factor. In many of the cases 
there is a bad neurotic family history ; epilepsy, chorea, hysteria, and other 
neuroses, which are characterized by feeble inhibition, have been noted. 
Rachitis and gastrointestinal disease, with improper food, impure air, and 
bad hygienic surroundings, are very important predisposing causes. 



EPILEPSY 691 

Prognosis. — The prognosis is commonly good. This syndrome, how- 
ever, in one or more of its manifestations may continue for months, but 
under proper care recovery finally occurs. The head movements, as a rule, 
disappear before the nystagmus. 

In making the prognosis in an individual case it is important that the 
neuroses above described be carefully differentiated from the same head 
and eye movements occurring in certain organic diseases of the brain, as 
well as these same movements occurring with the so-called imperative move- 
ments of defective children. These imperative movements in feeble-minded 
children very commonly take the form of a salaam, or repeated movements 
of the arm, trunk or leg. If such movements as these are associated with 
the syndrome under discussion, the prognosis is not so good. 

Treatment. ■ — The treatment is largely a matter of improving the child's 
general nutrition. Rachitis and the underlying gastrointestinal disease, 
if present, must be treated by diet and proper medication. A carefully 
selected diet, suitable to the age and digestive capacity of the child, is 
absolutely necessary ; fresh air and wholesome hygienic surroundings should 
be insisted upon. Cod-liver oil and some palatable and easily assimilated 
preparation of iron may be of value. Under this treatment the child's 
malnutrition gradually disappears, the nervous centers are better nourished, 
become less irritable, and the inhibitory centers of the cortex gradually 
assume more perfect control of the lower centers, and, as a result, the syn- 
drome disappears. 

Sedative medication may be indicated in beginning the treatment of 
some of these cases. Bromids may be given in from 3- to 5-grain doses 
three or four times in twenty-four hours, but they should be discontinued 
unless there is evidence that they are of decided value. 

EPILEPSY 

Definition. — The syndrome which, regardless of its etiology we call 
epilepsy is characterized by habitually recurring attacks of loss of con- 
sciousness and loss of motor coordination, which commonly find expres- 
sion in convulsive seizures either local or general. 

Etiology. — Epilepsy is produced by a variety of pathological conditions. 
It may be organic, due to some defect, disease, or injury of the nervous 
system, or it may be idiopathic, due to reflex toxic, constitutional or heredi- 
tary factors, the influence of which is not clearly evident. 

Age is an important etiological factor. The vast majority of these 
cases begin during childhood, and in a considerable percentage the early 
symptoms are manifest during the first year of life. 

Heredity as a predisposing factor is present in one-sixth of all cases, 
and' in one-third of those in which there is no evidence of organic disease 
of the nervous system. The family history may show epilepsy, infantile 
eclampsia, hysteria, insanity, migraine, or some other well-marked neurotic 
tendency ; or there may be a history of hereditary syphilis. 



692 GENERAL NERVOUS DISEASES 

Chronic malnutritions, especially those produced by rickets, chronic 
gastrointestinal disorders, and chronic heart disease, may be etiological fac- 
tors. Autointoxications, especially of the migrainous type, may assist in 
the production of epilepsy; the association of migraine and epilepsy is 
noted by all authors; in these cases there is commonly a family history of 
gout or of the arthritic diathesis. 

Reflex irritation, although perhaps not the most important causative 
factor, is closely associated with the development of many cases of epilepsy, 
and once the epileptic habit has been formed reflex irritation is one of 
the most common factors in precipitating attacks. Abnormal conditions 
in the intestinal canal, the eye, the nose, the throat, and the genitourinary 
organs are the most common causes of reflex irritation. Teething has also 
been mentioned as a reflex factor. 

Organic epilepsy has as its essential pathological factor some organic 
disease of the nervous system, such as agenesis, porencephalia, microcepha- 
lus cysts formed by a softening of the brain substance secondary to obstruc- 
tion of blood vessels, tumors of the brain and cord, traumatism producing 
fracture of the skull, and, most important of all, cerebral hemorrhages, 
especially minute punctate forceps injuries occurring as one of the acci- 
dents of birth, or traumas resulting from severe convulsions, or injury to 
the head in very early infancy. It had long been known that these in- 
juries to the brain were responsible for a large number of epilepsies, but 
a new interest was added to this subject by the admirable clinical studies 
of B. Sachs, who demonstrated that many obscure epilepsies developing in 
late childhood were focal epilepsies having their origin in cortical hemor- 
rhages, which occurred in infancy during or shortly after birth. In many 
of these cases epilepsy develops when the only remaining signs of the spas- 
tic palsy, which the original lesion produced, are increased reflexes and 
unilateral muscular weakness. 

Symptomatology. — Grand mod is the most important clinical type of 
epilepsy. It is characterized by a sharp cry, loss of consciousness, a fall, 
and tonic convulsive movements quickly succeeded by general clonic con- 
vulsions. The convulsive movements last for a few minutes, and are fol- 
lowed by a more or less profound sleep, from which the patient awakens 
convalescent from the attack, and with little or no knowledge of what has 
happened. 

Petit mal, or the minor attacks, is characterized by sudden loss of 
consciousness of short duration, sometimes only momentary, and by slight 
local convulsive movements, which may be confined to the fingers or face; 
these movements are often so slight as to escape attention. The patient 
recovers himself almost immediately and is usually conscious that an in- 
terval of unconsciousness has passed. 

Between grand mal and petit mal, which represent the extreme types 
of epilepsy, we may have great variations in the severity of the de- 
gree of unconsciousness and of the convulsive movements, and these 
gradations, together with the less characteristic symptoms that mark the 



EPILEPSY 693 

individual attacks, give great variety in symptom grouping to epileptic 
seizures. 

Jacksonian Epilepsy. — In these cases there is an unilateral lesion of 
the central nervous system which may or may not be evidenced by hemi- 
plegia, increased reflexes, or a weakness of the muscles of one side of the 
body. The distinctive characteristic of this type is a monospasm which 
may later become hemilateral or even general. The spasm commonly be- 
gins in a local muscle group, either in the hands or face. It may be lim- 
ited to this muscle group, or, as is usually the case, it may extend to one- 
half the body, or may result in general convulsions. There is, as a rule, 
no initial loss of consciousness, and consciousness may even remain unim- 
paired throughout the attack, except where severe general convulsions su- 
pervene. 

Nocturnal epilepsy occurs during sleep and may not manifest itself 
during waking hours. Feeble inhibition is an important factor in pro- 
ducing this type, the convulsions occurring when voluntary inhibition is 
lost in sleep. 

Preclusive epilepsy occurs only in childhood. The symptoms, usually 
of the "petit mal" type, are associated with involuntary running move- 
ments. 

Psychic epilepsy is very uncommon in the child. It is characterized by 
sudden loss of consciousness, the patient remaining motionless for a few 
seconds. It is not associated with convulsive movements or other symp- 
toms of epilepsy. 

Number of Attacks. — The habitual recurrence of attacks similar to 
those noted, stamps the condition as epilepsy. The number of attacks, how- 
ever, may vary greatly in individual cases. Many may occur in twenty-four 
hours, or an interval of days, weeks or months may elapse between them. 

Aura. — The aura includes the warning symptoms which foretell the 
inrpending attack. In focal or organic epilepsy of the Jacksonian type 
the aura is usually a local spasm in a special muscle group of the face, 
arm or leg; sensory disturbances may precede or supervene in the affected 
parts, and the local spasm is apt to be converted into an unilateral or 
general convulsion. In toxic epilepsy the aura may be vertigo, hemianopsia, 
or light and dark spots or flashes of light before the eyes. In idiopathic 
epilepsy there may be so-called sensory aura due to irritation of the cor- 
tical zones of special sense, such as a vague sensation in the stomach, a feel- 
ing of numbness or tingling in the extremities, general restlessness, irri- 
tability of temper, aphasia, or ocular or auditory phenomena. 

Loss of consciousness, which is the most characteristic symptom of the 
epileptic attack, has strange variations in its manifestations. In certain 
cases dream-like states with partial loss of consciousness may immediatelv 
precede or follow the attack. In petit mal the loss of consciousness is often 
so slight that the attacks are mistaken by the laity for dizziness, fainting 
turns, or conscious tricks. In grand mal the unconsciousness is profound 
and unmistakable. 



694 GENERAL NERVOUS DISEASES 

The convulsion, which is the next most characteristic symptom of the 
epileptic attack, varies greatly in severity and character. It may be so 
violent as to cause painful bruises and other serious injuries, or so slight 
that the momentary twitchings of the muscles of the face or hands may 
not be observed at all. 

Mental Symptoms. — In nearly all cases of epilepsy there are more or less 
nervous irritability and mental impairment ; in the psychic and toxic forms, 
however, this may be scarcely noticeable. In organic epilepsy the mental 
symptoms will depend upon the location and extent of the organic disease. 
Well-marked mental impairment is the rule, and idiocy is not uncommon. 
In idiopathic epilepsy there is retardation of mental development, so that 
the child may be considered backward or mentally deficient. In some 
instances there may be a peculiar cunning which enables the epileptic to 
commit acts of violence and so cover his tracks as to avoid suspicion. In 
the most aggravated cases a condition of status epilepticus or rarely hemi- 
epilepticus may result; it is characterized by frequent paroxysms, coma, 
exhaustion, elevation of temperature, rapid pulse and increased respiratory 
movements. These cases may terminate fatally. 

Diagnosis. — Grand mal may be confused with hysteria, but in this lat- 
ter condition the warning cry is absent; the loss of consciousness is not, 
as a rule, absolute; the pupils are not dilated; the eyes, instead of being 
turned upward and inward, stare into vacancy; there is no involuntary 
passage of urine and feces, and the narcotism following the attack is ab- 
sent. In the diagnosis of petit mal there is more difficulty, since the mother 
may not accurately describe these attacks. Special importance in these 
cases must, therefore, be attached to the marked change in temperament 
and increased irritability, which have occurred since these attacks made 
their appearance. 

Great importance attaches to the differential diagnosis of the various 
types of epilepsy. Organic or focal epilepsy is frequently mistaken for 
the idiopathic form, unless the physician in every case makes a careful 
search for organic disease of the nervous system. If Sachs' advice be 
followed to test in every case the comparative strength of the muscles of 
the right and left hand, and search for an exaggeration of deep reflexes, 
and, in older children, for the Babinski sign, as well as inquire carefully 
into the early history of the child for evidences of cerebral hemorrhage 
or other disease of the nervous system, many cases that have been classed 
as idiopathic will be found to be organic. Partial convulsions, which may 
or may not become general, persistent headaches, and optic neuritis may 
indicate organic epilepsy. Nocturnal epilepsy may exist unsuspected for 
a long time. In these cases the following symptoms occurring during the 
night are significant: biting the tongue, producing blood on the pillow, 
and incontinence of urine and feces, followed the next morning by lassi- 
tude, mental dullness, and headache. 

Prognosis. — About 10 per cent, of all cases of epilepsy get well under 
proper treatment. In organic epilepsy the prognosis is unfavorable, unless 



EPILEPSY 695 

early operative interference is resorted to; a few of these cases, however, 
due to syphilis, are improved by antisyphilitic treatment. In toxic epilepsy 
of short duration the prognosis is much better. In idiopathic epilepsy the 
prognosis is more favorable when the disease has lasted but a short time, 
and the interval between the attacks is of long duration, and where a po- 
tent and removable reflex factor is found, such as eye-strain. 

Treatment. — Where the aura precedes the attack a sufficient length of 
time to permit of treatment, inhalations of chloroform, or nitrate of amyl, 
may shorten or prevent the attack. During the seizure some foreign body 
should be placed between the teeth to prevent injury to the tongue, but no 
attempt should be made to forcibly restrain the violent spasmodic move- 
ments. 

General Treatment. — Some epileptics may be favorably influenced 
by suggestion; this may be a matter of environment or of medical or sur- 
gical treatment. Temporary improvement very commonly follows almost 
any radical change. Surgical operation, change of locality, or any new and 
promising line of treatment may lengthen the interval between the attacks 
to months, in cases where the interval has been days or weeks. In the be- 
ginning it is important that a careful search should be made for reflex 
factors. Eye-strain should receive special attention, and diseases of the 
nose, throat and genitourinary organs should be removed by proper sur- 
gical and other measures. 

In every case it is absolutely necessary to carefully study the func- 
tions of the gastrointestinal canal. Chronic indigestion and intestinal tox- 
emia are, in a large percentage of cases, important factors in aggravating 
the epilepsy. Constipation must be overcome, and the diet of the patient 
should be selected with reference to his age, idiosyncrasies and digestive 
capacity; careful feeding in selected cases may accomplish more than any 
form of medication. In all cases, alcohol, coffee, tea, sweets, salads, pastry, 
and an excess of albuminous food must be avoided. In young children it 
is frequently necessary to diminish the quantity of fats, giving skimmed 
rather than whole milk. 

A careful routine in the daily life of the child should be insisted upon. 
It should go to bed early and at a regular hour; fresh air day and night 
is important, and exercises suitable to the individual case should be pre- 
scribed. A quiet country life, free from noise and nervous irritation, is 
advisable. In mild cases mental training should be given at home, but 
not at school. 

Chronic malnutrition and anemia, whether produced by tuberculosis, 
rheumatism, heart disease, malaria, disease of the digestive organs, heredi- 
tary syphilis, or attacks of influenza, or other acute infections, should re- 
ceive appropriate treatment. 

Medical Treatment. — The bromid of potassium is the most valuable 
remedy we have in epilepsy. It is not simply palliative, but when combined 
with the general treatment above noted it may, in selected cases, be cura- 
tive. The curative effect of the bromids is probably dependent upon the 



696 GENERAL NERVOUS DISEASES 

fact that the epileptic habit is interrupted, in that the irritability of the 
cortical sensory centers is distinctly lessened, thus giving the child an 
opportunity to so improve under the general treatment that after a time 
the bromids may be discontinued without causing a return of the epileptic 
attacks. In the early treatment of these cases from 30 to 60 grains of 
the bromid may be used in twenty-four hours, the object being to care- 
fully graduate the dose, so that the paroxysm may be controlled without 
producing acne, gastrointestinal disturbances, and the general depression 
which may follow excessive doses. When the minimum dose of bromid has 
been found which will control the epileptic seizures, this dose should be 
continued for a year or more, and then gradually diminished during the 
second and third year. In nocturnal epilepsy a large dose of bromid should 
be given at bedtime. 

The following drugs are also recommended in epilepsy: opium, tinc- 
ture of belladonna, chloral, arsenic, and digitalis; the latter is indicated 
only when there is a complicating cardiac disease. Cannabis indica is of 
decided value in epilepsy associated with migraine. A warm alkaline bath 
followed by an alcohol rub exercises a sedative and favorable influence in 
many cases. 

Surgical Treatment. — The surgical treatment has been on the whole 
disappointing, because the favorable cases do not fall into the surgeon's 
hands early enough to give the best results. Sachs very clearly sums up 
our knowledge of this subject as follows : "In a case due to a traumatic 
or organic lesion an early operation may prevent the development of 
cerebral sclerosis. If early operation is not done the occurrence of epilepsy 
is a warning that secondary sclerosis has been established, and an opera- 
tion may prevent it from increasing. Operation must include the removal 
of the diseased area; here, if all other parts are normal, a cure may result. 
Under favorable conditions a few cases of epilepsy may be cured by sur- 
gery, and many more improved. ... I consider it important not to 
await the actual development of epilepsy; and if the brain has sustained 
any considerable injury, to remove the injured tissues, which, if allowed 
to remain, constitute a permanent menace to the future health of the 
patient. We shall be able to prevent the development of epilepsy very 
much more readily than we can cure it if once established." 

CHOREA 

{Sydenham's Chorea, St. Vitus' Dance, Chorea Minor, St. Anthony's 

Dance) 

This condition must be differentiated from habit spasm, organic 
chorea, and electrical chorea. 

Definition. — Chorea is a syndrome occurring chiefly in children, char- 
acterized by involuntary, inconstant, incoordinate, jerky, and purposeless 
muscular movements involving a part or all of the voluntary muscles and 
occurring only when the patient is awake. 



CHOREA 697 

Etiology. — Predisposing Causes. — Chorea may occur at any age; it 
is most commonly seen between six and fifteen; it is rare under three and 
a half years of age. It occurs from two to three times more frequently in 
females than in males. It is uncommon in the negro. It may occur at 
any season of the year, but is much more prevalent during the latter part 
of the winter and spring. The prevalence of this disease between the 
months of February and June is not altogether due to climatic conditions ; 
acute infections and the nervous strain of school life may perhaps be im- 
portant factors in increasing the number of cases during this season of 
the year. A family history of neurotic disease, gout, rheumatism, migraine, 
or tuberculosis is very common. Chronic anemia and chronic malnutri- 
tion are among the most important predisposing factors; children of this 
type have irritable, unstable, nervous systems, which make them very sus- 
ceptible to functional nervous diseases of all kinds, and especially to chorea. 
Chronic lymph-node tuberculosis, which is the most important anemia 
producer of childhood, is an important etiological factor of many cases of 
chorea. Chronic gastrointestinal disturbances and chronic malaria may 
also be etiologically related to chorea. 

Exciting Causes. — Toxins acting on the central nervous system are 
responsible for most of these cases. These toxins may be either bacterial 
or autogenetic, or they may be either systemic or intestinal. In the great 
majority of instances it is impossible to name the character or locate the 
origin of these toxins, and, on the other hand, it is altogether probable that 
there is a group of so-called idiopathic choreas associated with profound 
nutritional and functional disturbances of the brain, in which there may be 
a question as to the presence of any toxic factor. 

Rheumatism is the most important cause of chorea; it is present in 
from 25 to 30 per cent, of all cases. This percentage may be definitely 
ascribed to acute rheumatic fever, whose specific cause is unknown. .If, 
however, the term rheumatism is used loosely to designate the various forms 
of arthritis which follow such acute and chronic infections as tonsillitis, 
septicemia, tuberculosis, scarlatina, influenza, diphtheria, typhoid fever, 
measles, gonorrhea, and syphilis, then a much larger percentage of the 
cases of chorea will be found to accompany, or follow, this syndrome. All 
of the above-named acute infections, especially tonsillitis, tuberculosis, 
and scarlatina, are not uncommonly followed by chorea. 

Endocarditis is present in about 25 per cent, of the cases. Cheadle 
and many other writers have called special attention to the relationship 
which exists between tonsillitis, arthritis, endocarditis, and chorea. All 
heart murmurs occurring during chorea are not due to endocarditis. In 
many instances there may be a weakening or irritability of the cardiac 
muscles, producing a very distinct cardiac murmur, which disappears, 
leaving the heart in a normal condition, when the attack of chorea has 
subsided. The cardiac murmurs present in highly neurotic, anemic chil- 
dren are very commonly not of organic origin. The common association 
of endocarditis with chorea should lead one to suspect organic disease of 



698 GENERAL NERVOUS DISEASES 

the heart in all cases where a murmur is present, until it can be definitely 
proven that the heart is not diseased. 

Fright, which by nearly all writers is classed as one of the important 
exciting causes of chorea, is responsible for the onset of the attack in a 
considerable percentage of cases. The fright, however, is made potent by 
the presence of other very important predisposing factors, such as mal- 
nutrition and general nervous irritability. Among other exciting factors 
one may mention intestinal parasites, gastrointestinal diseases, eye-strain, 
diseases of the nose and pharynx, phimosis, masturbation, delayed menstru- 
ation, pregnancy and imitation. 

Duration. — The average duration is about ten weeks ; mild cases get well 
in two or three weeks, and severe ones may continue for months. Cases 
with severe cardiac lesions, or grave nutritional disturbances, may continue 
for six or more months. Those that continue for years are due to organic 
disease of the nervous system. 

Recurrence. — Children who have had chorea should be kept closely un- 
der observation for a number of years to prevent a recurrence. Attacks 
may recur at the same time of the year until the etiological factors which 
produced the first attack have been removed, or until age confers immu- 
nity; recurrences are not common after fifteen. Second and third attacks 
occur in about one-third of all cases. Children suffering from profound 
nutritional disturbances or from chronic diseases of the nose and throat, or 
from organic disease of the heart, are more likely to have subsequent at- 
tacks. 

Prognosis. — This is nearly always good. When death occurs it is due 
to cardiac disease or to the organic disease of which the chorea is a symp- 
tom. 

Symptomatology. — Characteristic Symptoms. — Before the character- 
istic symptoms of chorea develop, the child, as a rule, is anemic, nervous 
and irritable. At school the teacher may observe his inability to sit still 
and a clumsiness in the handling of objects. The dropping of pencils, 
books and other things brings reproof under which the child's restlessness 
increases. Later, twitchings of the muscles of the shoulder, face, or hand 
suggest the nature of the illness. In the early history of mild attacks the 
child may be able to partly control these irregular, purposeless, jerky 
movements, but the muscular spasm in these cases may be aggravated by 
directing it to perform some rather delicate movements, such as threading 
a needle, or lifting a pin from a smooth surface. The early awkwardness 
of choreic children may sometimes be noted by their tripping, stumbling 
gait, or by peculiar muscular contractions which momentarily distort the 
face. Very soon, following these early symptoms, unmistakable and more 
or less general choreic movements develop, and then the diagnosis may be 
made at a glance. 

There is probably no more clearly defined, or more characteristic, symp- 
tom group than that of well-marked chorea. The involuntary inconstant, 
incoordinate, jerky muscular contractions, involving the whole or part of 



CHOREA 699 

the body and aggravated by efforts to control them, present an unmistakable 
syndrome. These irregular muscular movements vary greatly in severity; 
mild, as a rule, in the beginning, and confined perhaps to one member of 
the body; in a short time they extend to the whole or half the body and 
increase in severity, until at the end of the second week they have reached 
their maximum. At this time in severe cases the muscular contractions 
are almost constant and the whole body may be undergoing bizarre move- 
ments, which twist or distort it to such an extent that the patient may be 
unable to maintain an upright position. The limbs are jerked and twisted 
in more or less constant movement, and every voluntary effort increases 
these incoordinate muscular contractions. In the less severe cases the 
child may be able to go about as usual, and have limited control of the 
spasmodic muscular movements, so that he is able to pick up a pin, button 
his clothes, or make letters with a pencil, but all voluntary movements of 
this kind are made after a few moments of deliberate preparation, and then 
the act is carried out with great rapidity. 

Speech may not be disturbed, but, as a rule, even in mild cases there are 
marked deliberation, hesitancy, and some irregularity. In more severe 
cases the choreic movements involve the tongue and muscles of the jaw, 
and produce an irregularity of the respiratory rhythm. In these cases 
the articulation is imperfect and jerky; the patient hesitates and then 
speaks rapidly. The control, however, of the muscles of articulation may 
be lost in the middle of a word or a sentence, and in severe cases articula- 
tion may be impossible. The muscles of the larynx may be involved, pro- 
ducing irregularity in the tone, pitch and volume of the voice; an effort 
to speak may produce a whisper, a barking sound, and other unusual 
noises. The muscles of deglutition may be affected, producing difficulty 
in swallowing. 

In severe cases of chorea the muscles become so exhausted by constant 
movement that they appear to be paralyzed. There may be also an actual 
loss of muscular power, and, in rare instances, this may amount to par- 
alysis. During sleep the choreic movements subside, except in the most 
severe cases; this muscular rest gives the tired muscles an opportunity 
to recover their tone. 

Choreic movements, as a rule, are general. In about one-quarter of 
the cases they are confined to one side of the body; these cases of hemi- 
chorea do not differ materially in other particulars from those which in- 
volve the whole body. 

Choreic children are usually quick-witted, irritable, emotional, and 
suffer from headaches and general nervous exhaustion. As the disease 
progresses they may become more irritable, disobedient and selfish. In 
very severe cases hallucinations, delirium, and even acute mania and melan- 
cholia may develop; these latter symptoms are extremely rare. 

Reflexes are so variable that they are of little diagnostic importance. 
They are commonly normal, sometimes quickened, or they may be dim- 
inished, and, in rare instances, absent. 



700 



GENERAL NERVOUS DISEASES 



Well-marked anemia is a very common symptom of chorea. 

Urine. — There is nothing specific in the urine findings; albuminuria 
and glycosuria are occasionally noted; uric acid, as a rule, occurs in excess. 
Herter demonstrated the presence of hematoporphyrin in the urine, both 
of chorea and rheumatism. 

Heart Symptoms. — In every case of chorea the heart should be watched 
throughout for evidence of cardiac disease. A rise of temperature with- 
out apparent cause is strongly suggestive of cardiac involvement. If a 
cardiac murmur develops, the case is to be treated as endocarditis. Prac- 
tically all of the diastolic murmurs are organic; systolic murmurs at the 
base near the sternum are commonly hemic and due to anemia; apical sys- 
tolic murmurs usually mean endocarditis, but they may be due to myo- 
cardial insufficiency, and entirely disappear during convalescence. Osier 
has called attention to the fact that many murmurs diagnosed as hemic or 
functional are later found to be organic. Pericarditis may also complicate 
chorea. 

Treatment. — General Treatment. — It should be remembered that 
chorea is generally self-limited, and that mild cases can, for the most part, 
be satisfactorily treated with little medication. 

In beginning the treatment all apparent sources of reflex irritation 
should be removed, and, above all, the intestinal canal should receive most 
careful consideration. A cathartic should be given, preferably calomel, 
followed by castor oil. Intestinal fermentation should be corrected by 
proper food and medication. The diet is important in all cases; the food 
should be selected to suit the individual child's digestive capacity. Milk 
is an ideal diet, unless intestinal disease or an idiosyncrasy forbids its 
use. Chicken and beef in small quantities may be allowed, and cooked 
fruits and easily digested vegetables may be given. Coffee, tea, strong beef 
soups, sweets, pastries, and all indigestible food are contraindicated. 

Rest, both of body and mind, is necessary. In mild cases it may be 
possible to get on fairly well without putting the child to bed, provided 
he is kept moderately quiet and not allowed to engage in childish sports 
with other children. In severe cases the child should be put to bed and 
kept there until the paroxysm commences to subside, and, thereafter, until 
convalescence is established, he should spend the greater portion of the 
time in bed. In the most severe cases the railing about the bed should be 
high and well-padded to prevent convulsive movements from throwing the 
child out of bed, or from injuring him by knocks against hard objects. 
The bodily rest, which is so important in the treatment of uncomplicated 
chorea, is even more important when there is a concurrent endocarditis. 
Mental rest is quite as important as bodily rest. Nervous strain and men- 
tal work should be reduced to a minimum. The tactful mother and nurse 
when properly directed will be able to interest the child without tiring or 
irritating him. 

Medical Treatment. — Arsenic is the most valuable remedy we have 
in the treatment of the attack. In some cases it undoubtedly exercises a 



HABIT-SPASM AND OTHEE HABIT NEUROSES 701 

controlling influence over the symptoms and shortens the duration of the 
disease. In giving arsenic one should commence with small doses, 2 
or 3 minims well diluted with water, three times a day. After a few 
days, when it has been ascertained that the arsenic will be tolerated, the 
dose is to be gradually increased until the patient is taking 10 or 12 minims 
three times a day; larger doses, as a rule, are unnecessary, and it is unwise 
to steadily increase the arsenic until the characteristic signs of arsenic 
poisoning are produced. These symptoms are headache, irritable stomach, 
diarrhea, and puffiness of the face, and should they make their appear- 
ance at any time during the administration of the arsenic, this drug should 
be at once stopped for a week or ten days, and then, if continued at all, 
should be given in small doses. In giving arsenic as above described the 
maximum dose of 10 or 12 drops should be continued for a few days only, 
and the dose should then be gradually diminished until the patient is 
taking from 3 to 5 drops three times a day. After giving the arsenic for 
two weeks, if decided improvement in the symptoms has not resulted, it 
should be discontinued. 

Sodium salicylate (wintergreen), aspirin, and salol may be used with 
advantage in rheumatic cases. Warm baths and mild laxatives, such as 
sodium phosphate, are of value. In cases associated with profound 
anemia and malnutrition, iron, cod-liver oil, and a diet of meat, eggs and 
milk are indicated. Quinin is of value only in those cases where there is 
a malarial intoxication. 

Sedative medication may be indicated in very severe cases. Chloral 
hydrate, veronal, and potassium bromid may be used to produce sleep, and, 
in rare instances, hydrobromate of hyacin, or morphin hypodermically, or 
chloroform by inhalation may be necessary to control severe muscular 
contractions. 

Following an attack of chorea, when the patient is thoroughly con- 
valescent, he should have his nose and throat carefully investigated. Ton- 
sils and adenoids enlarged by disease are open portals through which in- 
fections capable of producing chorea may enter the body; they should 
therefore be removed to prevent acute infections. Eheumatic cases may 
require a change of climate to avoid the damp, cold months of the winters 
in our middle and northern States. 

In the treatment of those cases in which there is an underlying pro- 
found anemia and malnutrition, the syrup of the iodid of iron, cod-liver 
oil, fresh air, good food, and appropriate hygienic measures should be con- 
tinued until the child is restored to health. 



HABIT-SPASM AND OTHER HABIT NEUROSES 

Habit-spasm, or tic, is a pure neurosis characterized by sudden and 
quick contractions which assume somewhat the character of convulsive 
movements. In the beginning these movements appear to be voluntary, 



702 GENERAL NERVOUS DISEASES 

but by repetition they become habitual and involuntary. They occur most 
frequently in the muscles of the face, neck and shoulders. 

Etiology. — Tic is in no way related to chorea. The clinical pictures 
which the two conditions present, and the etiological factors which pro- 
duce them, are quite different. Heredity is the most important predis- 
posing factor. These patients, as a rule, have unstable and easily ex- 
citable nervous systems inherited from neurotic ancestors. Tic is com- 
monly associated with other neurotic disorders. Malnutrition and anemia 
are frequently present. These exciting factors may be brought about by 
bad hygienic surroundings, improper food, chronic intestinal indigestion, 
chronic intoxications, systemic and intestinal, and, in fact, by any patho- 
logical condition which undermines the child's general health. Tic rarely 
occurs before the third year of life. It most usually has its onset be- 
tween the fifth and the fourteenth years. The development of the re- 
productive organs and school life are important causative factors. School 
life brings to bear on the irritable nervous systems of neurotic children 
the etiological factors which are most important in the development of 
habit-spasm. The mental training, confinement, restraint, enforced quiet, 
unhygienic surroundings, anxiety to excel, and increased eye-strain which 
school life entails may all be factors in aggravating the neurotic tenden- 
cies of nervous children, and more or less directly lead to habit-spasm. 

Imitation and reflex irritation from eye-strain, or disease of the eyes, 
nose, throat, and pharynx are among the common exciting causes of tic. 

Symptomatology. — The child is nervous, restless, quick of movement, 
and, as a rule, bright of mind. But the characteristic symptom is re- 
curring spasmodic movements in one or more groups of muscles, com- 
monly in the face, neck or shoulders. In an individual case the same 
movements are usually repeated. There may be rapid winking or blink- 
ing of the eyes, with the drawing of the mouth downward and to the side, 
distorting the face. The eyebrows may be raised or lowered, as in frown- 
ing. A sudden twisting or shaking of the head and shrugging of the shoul- 
ders are very characteristic movements. A peculiar inspiratory sniff 
with the lifting of the alse of the nostrils occurs in some cases. Hyper- 
esthesia of the skin may be associated with this condition. Habit-spasm 
of muscle groups in arms and legs may also occur, but is not common. 
The spasmodic movements in tic may recur at short intervals, especially 
when the patient is under observation. Attention to and discussion of 
these symptoms increases the frequency and violence of the contractions. 
They may almost or quite disappear during the vacation months if this 
time is spent in a quiet country place, and they may reappear when the 
child returns to school in the autumn. The worst cases are seen in the 
latter part of the winter and early spring months; in these there are usu- 
ally a well-marked malnutrition and anemia, and hemic and accidental 
cardiac murmurs may be heard over the base of the heart. 

Prognosis. — Habit-spasm, or simple tic, may continue for many months 
and even years; as a rule, however, the prognosis is good, provided the 



HABIT-SPASM AND OTHER HABIT NEUEOSES 703 

hereditary taint is not too strong and the child can be placed under the 
most favorable conditions for recovery. We are not here interested in the 
convulsive and psychical tics which may occur in older children and in 
adults. 

Treatment. — The treatment of simple tic should begin with the re- 
moval of all abnormal conditions which may possibly be a source of reflex 
irritation; eye-strain and nasal and pharyngeal irritation should receive 
special attention. The child should be taken out of school and have such 
mental training as is thought necessary at home. It should be protected 
from all forms of mental excitement, and its surroundings should be 
such that attention would never be called to the spasm. In young chil- 
dren the attendants should deny, if necessary, in the presence of the child, 
the very existence of the spasm. In older children rewards are sometimes 
efficacious. Children suffering from tic should not be permitted to play 
with other nervous children, since the disease by imitation may be com- 
municated to others. 

An outdoor life, peaceful, quiet surroundings, well-directed exercise, a 
carefully selected nutritious diet, and medication such as may be indicated 
to relieve the particular form of malnutrition, indigestion or intoxication, 
which may be the basic factor in an individual case, are in every instance 
part of the general treatment. It may be necessary by proper medication, 
diet, fresh air, and general hygienic measures to treat an underlying mi- 
grainous or uric acid diathesis, or a tuberculous anemia. 

Drugs are of little value in the treatment of this condition, but the 
bromids may be used for a time to control symptoms. 

Thumb-sucking is a habit neurosis which has its origin in the animal in- 
stinct of self-preservation which causes the infant to suck everything that 
comes in contact with its lips. The child by instinct conveys to its mouth 
everything that touches its hands, and when nothing happens to be in the 
hand the child places its thumb, ringers or some other portion of its body 
in its mouth. In this way the injurious habit of almost constant sucking 
is gradually developed. In the beginning the act is done in response to 
normal instincts, but after a time the sucking habit is gradually formed, 
and then the infant, during the greater portion of its waking moments, 
indulges this habit and 'seems to get comfort and satisfaction from the 
act. When this habit is once formed the infant does not, as in the begin- 
ning, suck promiscuously anything that happens to come in contact with 
its mouth, but confines the habit to some particular object, such as a 
thumb, finger, toe, the tongue, a rubber nipple, a piece of cloth, or some 
special toy. 

The habit of sucking does not produce any notable constitutional dis- 
turbances and does not apparently influence the growth and development 
of the nervous system, and the infant is allowed to form this habit be- 
cause the mother or the physician does not believe it is worth while to try 
to prevent the formation of a habit which gives the child a pleasurable 
occupation and does not seriously interfere with its development. The 
46 



704 



GENERAL NERVOUS DISEASES 



sucking habit, however, does produce certain deformities of the part 
sucked, and may also lead to irregularities in the development of the 
mouth. The deformities of the mouth, thumbs and fingers may, in ag- 
gravated instances, be so pronounced that they are noticeable when the 
child grows up. It is for the purpose of preventing these deformities that 
the sucking habit should be corrected. 

If the child is allowed to indulge in this habit for months or years, it 
may be necessary to use some mechanical device which makes it impos- 
sible for the child to continue it. When the habit has been indulged in for 
only a short period of time, it may be possible to overcome it by covering 
the thumb, fingers, or parts sucked with bandages or mittens carrying so- 
lutions of quinin or aloes. These bitter solutions, however, are of little 
value when the habit is well formed. The mechanical means which may 
be used may vary with the individual child and with the part of the body 
sucked. Punishment, as a rule, does not favorably influence this habit, 
but rather teaches the child deception. Older children may be influenced 
by rewards or by appealing to their sense of shame. The sucking habit is 
always more difficult of treatment in nervous, malnourished children, and, 
for this reason, malnutrition and other causes of nervousness should be 
carefully treated before an attempt is made to break up the habit of suck- 
ing by mechanical restraint. 

PICA 



Pica, or dirt-eating, is a habit neurosis which manifests itself in a 
curious perversion of appetite. The infantile type of this disease, in which 
we are here interested, commonly begins before the second year of life 
and tends to spontaneous recovery before the fifth year. The animal in- 
stinct of self-preservation which causes the infant to put everything it 
touches into its mouth is the most important factor in starting this neuro- 
sis. It occurs most commonly in neurotic, malnourished children, and is 
very frequently associated with gastrointestinal disorders. In older chil- 
dren imitation is an important factor. Functional disturbances of the 
stomach, which produce a burning, gnawing sensation that is relieved by 
the eating of dirt, chalk, Fuller's earth, and other absorbents, may be im- 
portant and troublesome factors in developing and continuing this habit 
neurosis. Whatever may be the predisposing or exciting causes which have 
been active in starting the practice of dirt-eating, the habit which is thus 
formed becomes the important etiological factor which impels the patient 
to continue to satisfy this perverted appetite. 

Symptomatology. — The strange perversion of appetite in these children 
causes them to forego wholesome, appetizing food for such innutritious and 
indigestible things as dirt, plaster, sand, gravel, chalk, Fuller's earth, clay, 
ashes, cinders, coal, soapstone, slate-pencils, paper, rags, hair, and some- 
times such disgusting materials as their own excrement. In some instances 
children will refuse to take all foods except sweets, such as candy and 



HYSTERIA 705 

sugar ; this sugar-eating habit may lead to dirt-eating, and the development 
of troublesome and disgusting types of pica. Many patients who practice 
the habit of dirt-eating may take for a considerable time a sufficient quan- 
tity of nutritious food; as the habit develops, however, the tendency is to 
gradually increase the quantity of dirt taken and diminish the quantity 
of food. Such patients may become anemic, malnourished and emaciated, 
and may develop intestinal disorders. 

Prognosis. — This is good. The great majority of these cases recover 
under proper treatment before the child is three years of age. A few of 
them continue into the third or fourth year, and neglected cases may de- 
velop into the more severe forms of pica seen in late childhood and adult 
life. 

Treatment. — The first step in the treatment is to place these patients 
under such supervision that it is absolutely impossible for them to con- 
tinue the habit; if the habit is forcibly broken it gradually loses its hold 
upon the nervous system, and this measure is, therefore, a curative one. 
The next important step is to prescribe a proper dietary, suitable to the 
age and digestive capacity of the patient. The food problem is especially 
important, since the dietetic treatment usually comprehends the removal of 
some gastrointestinal irritation. In cases where food is absolutely re- 
fused (anorexia nervosa) it may be necessary to feed by gavage. Alkalies 
such as bicarbonate of soda or benzoate of soda exert a favorable influence 
in these cases; they may perhaps act by neutralizing fermentation and 
other acids in the stomach, and thus correct one cause of the perverted 
appetite. 

HYSTERIA 

Definition. — Hysteria is a psychoneurosis due to functional disturb- 
ances of the cortical centers. It is characterized by defective will power, 
emotional excitability, and the control of the body and mind by perverted 
notions and fixed ideas, which are not uncommonly produced by sugges- 
tion. 

Etiology. — Hysteria is a real, not a simulated, disease. Its most im- 
portant etiological factor in the child is feeble inhibition; this lack of 
control results in apparently insignificant causes producing exaggerated 
motor and psychic phenomena. Hysteria is more common in the adult 
than in the child, but is not infrequently seen in late infancy and early 
childhood, and is very common between the ages of ten and fifteen. Hered- 
ity is a very powerful predisposing factor; a strong neurotic taint is 
commonly present. There may be a family history of hysteria, chronic al- 
coholism, epilepsy, insanity, chorea, or general nervous irritability. The 
worst cases occur in families that are mentally degenerate. There is a 
marked preponderance of females, but this is not so great in children as 
in adults. 

Malnutrition is one of the important direct causes of hysteria in chil- 



706 



GENERAL NERVOUS DISEASES 



dren. The term malnutrition is here used very broadly, not only to in- 
clude innutrition and partial starvation of nerve cells, which result from 
lack of sufficient food and bad hygienic surroundings, but it also compre- 
hends the condition of nerve cells which results when they are fed with 
blood containing auto, intestinal or bacterial toxins. Not only poor blood, 
but bad or poisoned blood, is important in the etiology of hysteria in in- 
fancy and childhood. 

Environment is a very important exciting cause. Hysteria is more 
common in the city than in the country, not only because of impure air 
and bad hygiene, but also because of the noise, the rush, and the strain of 
life in a large city, where the child is subjected to constant excitement and 
increased mental activity. The strain of school life and school examina- 
tions, the lack of home discipline, which allows self-indulgence and free 
play to the emotions, and the close association of members of a neurotic 
family may all be factors in the development of this disease. Great grief, 
emotional excitement, great physical or mental strain, nervous shock, and 
sudden fright may develop hysteria in those predisposed to this disease by 
malnutrition or heredity. Severe reflex excitation, such as may come 
from eye-strain, intestinal disorders and phimosis, are important factors. 
Diseases of the genital organs may produce hysteria in infants and young 
children. Suggestion is one of the most potent factors in developing 
symptom groups in hysterical patients. Syndromes may be suggested by 
the questions of the examining physician or by the story of another pa- 
tient's symptoms and sufferings. 

Symptomatology. — Extreme selfishness and dependence are common 
manifestations of hysteria. The defect in will power makes the patient 
dependent upon those around her. She is often controlled by fixed ideas 
with reference to her inability to think or act for herself. One of the 
most peculiar and characteristic examples of the control which fixed ideas 
have over hysterical patients is shown in the symptom group known as 
astasia-dbasia. This is one of the most common of hysterical manifesta- 
tions in the child, and, whatever may have been its origin, it is continued 
by reason of the fact that the patient has a fixed idea in her mind that 
she can neither stand nor walk. She may have control of her legs when 
lying down, moving them at will in any direction, but the minute she is 
placed upon her feet her legs give way, or they stiffen and she loses her 
equilibrium, or she may stand upon her feet and not be able to walk, 
making incoordinate movements of the legs when she attempts to do so. 

Paralysis, which is a common manifestation of hysteria in the adult, 
is comparatively rare and of a milder type in young children. It may be 
flaccid and associated with diminished reflexes, but it is commonly spas- 
tic, associated with contractures and exaggeration of deep reflexes. Anes- 
thesia, which is so common in the adult, and often associated with motor 
paralysis, is comparatively rare in the child. The paralysis and anes- 
thesia of the hysteria of childhood do not differ from these symptoms as 
they occur in the adult, except that they are less frequent and less intense. 



HYSTEEIA 707 

Painful and contractured joints occur not infrequently, even in very 
young children. These hysterical manifestations may be mistaken for tu- 
berculosis or other organic disease. Hysterical aphonia occurs in children. 
This symptom is very commonly associated with globus hystericus, and a 
persistent dry, hysterical cough. Hysterical eclampsia is rare in young 
children, but may occur in older children, and presents the same charac- 
teristics as it does in the adult. 

In the emotional forms of hysteria fits of crying and laughing may 
follow each other without apparent cause. These patients are moody, ir- 
ritable, and are easily thrown into states of great nervous excitability. In 
extreme cases catalepsy, lethargy, trance, ecstasy and even acute mania 
may occur; these latter symptoms, however, are very rare in the child. 

Anorexia nervosa is a classical symptom group which is very common 
even in young children, and it may occur in infancy. In this condition 
the patient may go for weeks without being seen to retain any food; the 
sight of food may produce nausea, and all food taken may be vomited, 
sometimes with a conscious effort. The severity of this symptom group 
may vary greatly; in young infants it may take the form of lack of ap- 
petite, so that all food is refused. In these cases it may be necessary to 
resort to gavage to prevent loss of weight and serious malnutrition. 

The urine during hysterical attacks is light colored, of low specific 
gravity, and is commonly passed in large quantities. Anuresis may also 
occur. 

Treatment. — In beginning the treatment of hysteria it is important 
that all causes of reflex irritation to the nervous system should be removed. 
Eye-strain, diseases of the nose, throat, reproductive and genitourinary 
organs should receive appropriate treatment. 

The next step comprehends the removal of the underlying causes of 
the chronic anemias and malnutritions so commonly found in hysterical 
patients. In order to do this it is not only necessary to prescribe medi- 
cines, such as iron, cod-liver oil, arsenic, quinin, or some tonic that will 
stimulate the appetite and improve digestion, but it is of even greater im- 
portance that the diet and hygienic surroundings should be carefully 
adapted to the needs of the individual case. Alcohol, tea, coffee, sweets, 
salads, pastries, and rich and highly seasoned dishes should be avoided, 
and a diet prescribed which is simple, wholesome, nutritious and suitable 
to the digestive capacity of the patient and the malnutritions from which 
she suffers. The hysterical patient should live as much as possible out of 
doors, away from the whirl, noise and excitement of a city, and moderate 
exercise and congenial surroundings should be insisted upon. 

Eemoval from the nervous atmosphere of a neurotic household, stop- 
ping of all mental stimulation, and avoiding nervous excitement are im- 
portant factors in the cure. The hysterical patient should, if possible, be 
placed under the care of a nurse whom she loves and in whom she has con- 
fidence. This attendant should be of good physique, of sober mind, and 
full of tact, and she should have sufficient intelligence to study the pe- 



708 GENERAL NERVOUS DISEASES 

culiarities of her patient's mental condition so that she may tactfully avoid 
touching upon topics which by suggestion may influence her patient un- 
favorably; she should also be able to utilize the fads and idiosyncrasies of 
her patient in such a way as to prevent her from dwelling upon her 
troubles. The successful treatment will depend largely upon the ability of 
the physician to so control the surroundings of his patient that she will be 
constantly influenced by wholesome suggestions — suggestions that she is 
improving from time to time, and that her early recovery is assured. The 
influence of change is so important that it is necessary that radical 
changes should be made in the surroundings from time to time. In older 
children a modified Weir Mitchell rest-cure is often of great advantage. 
The confinement to bed, massage, forced feeding, isolation, and striking 
change of surroundings, which this treatment comprehends, act not only 
by suggestion, but the treatment itself exercises a curative influence. Hy- 
drotherapy in some form is applicable to the treatment of nearly every case 
of hysteria; the cold tub bath, or cold douche to the spine, may be used 
in older children to control severe paroxysms. In the great majority of 
cases a warm bath followed by general massage and an alcohol rub is of 
great advantage. Electricity is a therapeutic agent, which acts largely 
by suggestion; in the treatment of aphonia and paralyses of various kinds 
it is especially valuable. Blistering the skin over tender areas and cau- 
terizing the sensitive spine may be of benefit in some cases. 

Sedatives, such as the bromids, valerian and asafetida, may be used 
for the relief of nervous symptoms, but they should not be continued for 
any great length of time. 

HEADACHES 

Etiology. — Headaches are uncommon in children under five years of 
age, but when they do occur they are much more important in their patho- 
logical significance than when they occur later. After five years of age 
headaches are more frequent, and become common between the ages of 
eight and fourteen, but even during this period they are nothing like so 
common as they are between the ages of twenty and forty. 

Heredity is an important predisposing factor; this is especially true 
of migrainous, neurasthenic, and neuralgic headaches. These cases usually 
have a family history of gout, migraine, neurasthenia, hysteria, or general 
nervous instability. Feebleness of constitution due to chronic diseases in 
the parent may be inherited by the child and predispose it to reflex, toxic, 
anemic and other varieties of headache. 

Anemic Headache. — Malnourished, anemic, neurotic children may 
have headaches from very slight exciting causes, and the pain is common- 
ly frontal, or vertical. Any chronic disease which produces malnutrition 
and anemia results in such instability and irritability of the vasomotor 
nerve centers that headaches may be produced by nervous excitement, 
nervous and physical fatigue, nervous shock, fear, anger, mental overwork, 



HEADACHES 709 

the strain and confinement incident to school life, and by all kinds of toxic 
and reflex factors capable of acting upon the nervous system. 

Keflex headaches are very common in childhood, especially between 
the ages of six and fourteen. They may be due to eye-strain, adenoid 
growths, undigested food, and other reflex causes. Ocular defects are very 
common in children of school age, and are responsible for a large percen- 
tage of the chronic headaches from which school children suffer. These 
headaches come on after using the eyes and grow worse toward the close 
of the school day; they are usually frontal or occipital and associated with 
general nervous irritability. 

Toxic headaches of gastrointestinal origin are common in childhood 
and may be associated with nausea, vomiting, flatulency, diarrhea, or 
constipation. The diagnosis of headaches of this character may be con- 
firmed by the relief which follows cathartic medication and careful dietetic 
treatment. In children over six years of age they may be more or less 
chronic, persisting for weeks, and the intestinal toxemia during this time 
may be overlooked. In this type the presence of indican and indolacetic 
acid in excess in the urine may call attention to their intestinal origin. 

Toxic headaches are also produced by systemic bacterial poisons acting 
on the nerve centers. This type occurs in all the acute infectious diseases 
and is especially severe in influenza. Periodic headaches, neuralgic in 
character, are very commonly due to influenza or malaria; the supra- and 
infraorbital nerves are frequently involved and remain sensitive to touch 
in the interval between the attacks of pain. In older children infections 
involving the antrum of Highmore, frontal sinus and other bony cavities 
of the face may produce a persistent, periodic pain in the facial nerves, 
which may be mistaken for malarial or influenzal neuralgia. 

Autotoxins such as occur in uremia may produce severe toxic head- 
aches. Uremic headaches, however, are much less severe in the child than 
they are in the adult. They are commonly occipital and are associated 
with vertigo, nausea, vomiting and the urine findings of acute Bright's 
disease. Migraine, the most common form of headache produced by auto- 
toxins, is elsewhere described. 

During infancy and early childhood disease of the internal ear is the 
most common form of pain in the head. 

Organic headache may be due to meningeal inflammation, tumors of 
the brain, cerebral abscess, and injuries to the brain and skull. Head- 
aches of this character are severe, persistent, localized, and accompanied 
by other signs of organic disease of the brain or its membranes. 

Treatment. — The successful treatment of headaches in childhood must 
be based upon a careful differential diagnosis of the various etiological 
factors and their relative importance. A search should first be made for 
reflex factors, giving special attention to eye-strain. If such causes be 
found, they should be removed by appropriate treatment. Attention should 
next be directed to the gastrointestinal canal. It is good practice to begin 
the treatment of all kinds of headaches with some form of cathartic 



710 GE1STEKAL NEKVOUS DISEASES 

medication, such as calomel, followed by castor oil. This will clear the 
intestinal canal and assist materially in determining the importance of the 
role which gastrointestinal factors play in producing the headache. If the 
result of this treatment, the character of the headache, and the nature of 
the gastrointestinal discharges justify the diagnosis of toxic headache 
of intestinal origin, then the further treatment will consist in such diet 
and medication as will remove the causative condition. If, however, the 
headache is produced by some acute bacterial infection, such as influenza, 
it may be relieved by cathartic medication, the application of cold to the 
head, and the specific treatment of the infection of which it is a symptom. 
In these cases one is justified in using sedative medication to relieve the 
pain. For tins purpose the bromids of sodium and potash, citrate of 
caffein, phenacetin and antipyrin may be given in doses suited to the age 
of the child. The coal-tar products, however, are to be recommended only 
in the treatment of acute conditions, and should be continued only for a 
short time; in chronic or recurrent headaches their continued use may 
do harm. 

When the exciting cause of the headache is some emotional or nervous 
excitement brought on by fear, anger, or nervous shock, or when the head- 
ache is associated with extreme nervous irritability, or other hysterical or 
neurasthenic symptoms, an ice-bag to the head and good-sized doses of 
bromid act kindly in its relief. 

Periodic headaches may be relieved by good-sized doses of quinin given 
in the interval between the attacks of pain, or the following combination 
of quinin, arsenic and iron may be used. It is of special value not only 
in periodic, but also anemic, headaches: 

IJ Quinina? sulph ? ss 

Ferri reducti j ss 

Acidi arseniosi grg gg 

M. Make capsules; number 20. 

S. One after eating for a child eight to ten years of age. 

It should be remembered that even after the headache has been re- 
moved by any of the above-named measures there may yet remain to be 
treated the constitutional causes of the general nervous irritability which 
was the important predisposing cause of the headache. This treatment 
comprehends not only fresh air, proper exercise, suitable food and well- 
directed medication, but also the intelligent direction of the whole life 
of the child, so that he may be properly nourished, his constitutional and 
local diseases eradicated, and his nervous system so protected that it may 
recover its normal tone and powers of resistance. 

ASTHMA 



Asthma is a neurosis characterized by recurrent attacks of spasmodic 
dyspnea, or sibilant bronchitis, usually associated with, or followed by, a 
discharge of mucus from the bronchial tubes. 



ASTHMA 711 

Etiology. — The underlying causes of asthma are not definitely known, 
but it is a well-established fact that in this condition there is a definite 
specific underlying predisposition which makes it possible for a great 
variety of exciting causes to produce an asthmatic attack. The specificity 
of the underlying predisposing cause is demonstrated by the fact that the 
same exciting cause is nearly always present in an individual case, and 
that the many exciting factors which precipitate attacks of asthma in cer- 
tain individuals may in others be altogether impotent in producing an 
attack. 

The bronchostenosis which occurs in all cases of asthma is believed 
to be due, in some cases, to a vasomotor disturbance producing a swelling 
of the mucous membranes or of the submucous tissues of the bronchioli, 
but in the great majority of cases it is due to a tonic contraction of the 
muscle fibers of the smallest bronchial tubes. 

Asthma is much more common in adult life, but it may occur in in- 
fancy and early childhood; sibilant bronchitis is relatively more common 
in childhood. Typical attacks of spasmodic asthma become more common 
after the sixth year of life, and increase in frequency between this period 
and adolescence. Heredity is an important factor; there is nearly always 
a family history of neurotic disease or gout. Autotoxins of the gouty or 
lithemic diathesis may precipitate attacks of asthma. Comby classes among 
the respiratory manifestations of lithemia in childhood spasmodic coryza, 
sibilant bronchitis, and asthmatic attacks (see Eecurrent Coryza). Intes- 
tinal toxemia is an important exciting cause in children. Asthmatic at- 
tacks may be precipitated by constipation, overloading the stomach, in- 
testinal indigestion, and gastrointestinal disturbances of various kinds, 
or they may precede or follow urticaria of the skin. Diseases of the res- 
piratory tract, such as catarrh of the nasopharynx, hypertrophied turbi- 
nated bones, enlarged tonsils, adenoids, bronchitis, whooping-cough, in- 
fluenza, and measles, may be exciting causes. 

In especially susceptible individuals the pollen of certain grasses and of 
rag-weed, emanations from animals, such as the dog, horse, cat, or guinea- 
pig, the aroma of certain medicines, and the odor of certain flowers may 
be specific exciting causes. Among other exciting factors may be men- 
tioned dust, irritating vapors, fright, and atmospheric and climatic con- 
ditions. 

Symptomatology. — Asthmatic attacks resembling the adult type, while 
comparatively rare in the infant, are not infrequent in older children. 
They may recur at irregular intervals, weeks or months intervening. The 
severe dyspnea which characterizes these attacks may recur nightly for a 
time, or in other instances may continue with marked severity for twenty- 
four or thirty-six hours, and then gradually subside into convalescence. 
Typical attacks of asthma, as a rule, begin suddenly in the night with a 
wheezing respiration, which soon becomes a marked dyspnea. The child 
sits up in bed, fixing his shoulders or arms so as to bring all the acces- 
sory muscles of inspiration into play in the attempt to force air through 



712 



GENERAL NERVOUS DISEASES 



the contracted bronchi into the already distended air vesicles. Emphysema 
develops and gives a barrel-shaped appearance to the chest in the later 
stages of the attack. Expiration is prolonged and accompanied by sono- 
rous wheezing rales; the vesicular murmur may be inaudible. After a 
number of hours the dyspnea gradually subsides, and is, as a rule, followed 
by a cough with wheezing large moist rales, and more or less mucous ex- 
pectoration. These symptoms may continue for a few hours or for days 
and subside into convalescence. 

In infants and young children afebrile sibilant bronchitis with slight 
dyspnea is much . more common than the asthmatic paroxysm above de- 
scribed. The dyspnea in this condition may not be very great, but the 
number of respirations is markedly increased, and sibilant, wheezy bron- 
chial sounds occur, which may persist for five or six weeks. During this 
time these patients have no pain, suffer comparatively little discomfort, 
go about the house and amuse themselves without complaining of feeling 
ill. 

La Fetra calls special attention to the eosinophilia which occurs in 
asthma. He says : "The leukocytes are usually, but not always, increased 
as in bronchitis, but a differential count of the white cells shows, what 
does not occur in bronchitis, a constant and usually marked increase in the 
number of polymorphonuclear eosinophiles (16 to 18 per cent.)." 

Prognosis. — Patients rarely die from asthma, and the prognosis, so far 
as ultimate recovery is concerned, is also fairly good, provided they are so 
situated that they can take advantage of the means offered for its cure. 
Chronic cases, which have gone on to the development of chronic emphy- 
sema, do not yield readily to any form of treatment. 

Treatment. — Treatment of the Attack. — Fresh air and the inhala- 
tion of the fumes of stramonium leaves and niter paper may relieve the 
paroxysm; chloroform by inhalation will temporarily arrest the attack. 
In older children 1/10 of a grain of morphin given hypodermically may be 
used to terminate the paroxysm. Atropin, 1/1,000 of a grain, with nitro- 
glycerin, 1/300 of a grain, given hypodermically, has a favorable influence 
in controlling the paroxysm ; if necessary this dose may be repeated in two 
or three hours. An emetic will sometimes cut short a paroxysm of asthma, 
even when the gastric contents have little to do with exciting the attack; 
syrup of ipecac may be used for this purpose. Tincture of belladonna, or 
atropin, combined with bromid of potash, chloral, or antipyrin, in doses 
suited to the age of the child, is a valuable remedy for modifying, short- 
ening or preventing an attack. 

Asthmatic attacks due to swelling of the bronchial mucous membrane 
may be cut short by local applications to the respiratory passages of a 
solution of cocain and adrenalin chlorid. The 1 to 1,000 solution of 
adrenalin chlorid may also be used hypodermically in 1 to 3-minim doses; 
this remedy at times acts specifically in controlling attacks of asthma. 

The Interval Treatment. — Adenoids, large tonsils, nasal hypertro- 
phies, and all diseases of the nose and throat should receive appropriate 



ASTHMA 713 

treatment. Bronchitis, whooping-cough, measles, influenza, and all dis- 
eases which produce catarrh of the bronchial mucous membranes should 
be studiously avoided, or, if present, should be carefully treated until all 
bronchial irritation has disappeared. 

If the patient has a well-marked lithemic history, the interval treat- 
ment should be similar to that recommended in the chapter on Migraine. 
If no such history exists, or if the patient fail to respond to this treat- 
ment, iodid of potassium or syrup of hydriodic acid should be given over 
a long period of time. In many cases iodin medication is very valuable in 
•helping to bring about a cure, and should, therefore, be given a trial in 
every case in which some other special form of tonic medication is not 
especially indicated. Cod-liver oil, iron, arsenic, and tincture of nux 
vomica are of value in many cases, and quinin is indicated in such as 
have previously suffered from malaria. All medicines which diminish the 
appetite, or produce gastrointestinal disturbances, are to be avoided. 

Asthmatic attacks associated with urticaria of the skin should be 
treated as outlined under Urticaria. 

Change of climate, or change of locality, is the most important factor 
in the relief and cure of asthma. But in this respect it is difficult to lay 
down rules, since asthmatic patients, above all others, have the strongest 
idiosyncrasies with reference to certain localities and certain climates; a 
climate or locality that may benefit one may fail to give relief to another. 
These patients, as a rule, do well in high and dry altitudes, unless they 
have chronic emphysema. Experience alone will determine the best lo- 
cality for the individual asthmatic patient. It is a good rule, however, 
to avoid the locality in which the attack developed, especially at the sea- 
son of the year when attacks are liable to occur. If the attack has developed 
in the city, a change to the country is advisable, and vice versa. If the 
attacks are worse in winter, or if they are precipitated by recurring at- 
tacks of bronchitis, it is advisable to spend the cold, damp months of the 
year in some such climate as that of northern California or Florida. 

It may be well to note that patients suffering from an asthmatic con- 
stitution are not good subjects for the serum treatment commonly used 
in certain acute infections, such as diphtheria and sepsis. Sudden prostra- 
tion and sometimes death may result from the use of serum in these cases. 



SECTION XII 

DISEASES OF THE EAR 

CHAPTER LXXXIII 



OTITIS MEDIA AND MASTOIDITIS 



OTITIS MEDIA 



Etiology. — This disease is more common in infancy and childhood than 
later in life. The reasons for this may be found in the fact that the 
Eustachian tube at this time is shorter, larger, more patulous and opens 
lower in the pharynx than in the older child, and that the acute infectious 
diseases and acute pharyngitis, of which otitis media is a complication, are 
more frequent during this period. 

The essential cause of otitis media is an infection of the middle ear 
with bacteria which have found their way from the pharynx through the 
Eustachian tube. Staphylococci, streptococci, pneumococci, and influenza 
bacilli are the most common microorganisms producing this condition. 
Diphtheria, tubercle, typhoid and the pyocyaneus bacilli may occasionally 
act as exciting factors. Some of these microorganisms are usually found 
on the normal mucous membranes of the nose and pharynx, or in the crypts 
and fissures of chronically enlarged tonsils and adenoids. This is one of 
the important reasons why otitis media is such a common complication of 
acute pharyngitis, tonsillitis, influenza, epidemic grippe, measles, scarlet 
fever, diphtheria, pneumonia, bronchopneumonia, whooping-cough, gastro- 
enteritis, congenital syphilis, and typhoid fever. In fact, any disease 
which lights up an acute inflammation of the nasopharynx, or which great- 
ly reduces the vitality and resisting power of the individual child against 
catarrhal diseases, may be complicated or followed by an acute otitis 
media. Some of the microorganisms, such as the influenza bacillus and 
the pneumococcus, which are distinctly related to definite acute infec- 
tious processes, may have a special predilection for producing otitis media. 
When infection is present in the pharynx this disease may rarely be pro- 
duced by swimming under water, by douching, and by blowing the nose. 
In such cases the infection is forced from the pharynx through the Eus- 
tachian tube into the middle ear. 

Symptomatology. — Otitis media is almost always a secondary disease. 

714 



OTITIS MEDIA 715 

It is frequently masked by the infection of which it is a complication, 
and its onset may be obscured or modified somewhat by the presence of 
fever, pain and other symptoms due to other causes. In the majority of 
instances, however, the onset is announced by a sudden and marked rise 
of temperature following an attack of influenza or some other acute in- 
fection. The temperature in a few hours may reach 104° or 105 °F., and 
is usually associated with more or less earache, indicated by the crying 
and fretfulness of the child. In some cases, however, acute symptoms are 
absent, and the first manifestation of the disease is a discharge from the 
external ear. This form of onset may occur in very young infants and in 
older infants suffering from congenital syphilis, chronic glandular tuber- 
culosis, or chronic gastrointestinal disease. In these cases there may be 
no fever and no pain during the course of the disease, or the fever without 
the pain may appear following the perforation of the eardrum and the 
discovery of the discharge from the ear. In other cases a high and remit- 
tent fever may be present for days without any pain or other symptoms 
to call attention to the ear. In view of this fact, therefore, it is a wise 
precaution to carefully examine the eardrum and pharynx of every child 
suffering from obscure fever. Otitis media and mastoiditis are among the 
most common causes of unexplained remittent and intermittent fevers in 
young children. In rare instances these temperatures may continue for 
many weeks before there is marked evidence either in the eardrum or over 
the mastoid process of middle ear or mastoid infection. 

The course of the fever in otitis media is variable. It commonly con- 
tinues until the eardrum is perforated by the pressure of the fluid from 
within or by operative measures from without. Following the perfora- 
tion and the free discharge of pus the temperature falls, and if the drain- 
age from the internal ear remains good the temperature remains at or near 
normal. In such cases, however, a secondary rise in temperature common- 
ly means either the blocking up of the opening in the eardrum or the 
extension of the disease to the mastoid cells. The subsequent course of 
the temperature in such cases will depend, on the one hand, upon re- 
establishing the drainage from the middle ear, and, on the other, upon 
relieving the inflammation in the mastoid cells by operative or other 
measures. 

Earache in older children is very common, and only in the minority 
of cases is it a symptom of otitis media, but when it continues at intervals 
for more than twenty-four hours and is associated with an unexplained 
elevation of temperature it indicates middle-ear inflammation. It is diffi- 
cult in a child not old enough to locate pain to determine the existence 
of an earache, but it may be suggested by unexplained irritability, sleep- 
lessness and paroxysms of crying, and sometimes the child by its position 
protects, or with its hand reaches for, its ear. 

Otoscopic Examination. — The diagnosis of otitis media is made by dis- 
covering a discharge from the ear or by a careful examination of the ear- 
drum. The difficulty, however, of determining the existence of an otitis 



716 



OTITIS MEDIA AND MASTOIDITIS 



media from an examination of the eardrum is ofttimes so great that a 
specialist should be called upon to determine the significance of the find- 
ings of such an examination. The child with its arms at its side should 
be wrapped in a sheet, and its body and head firmly held by an assistant. 
The operator then draws the auricle downward and backward and inserts 
into the ear a speculum of proper size and shape, then with a head-mirror, 
or an electric head-light, he can, by illuminating the canal, bring the ear- 
drum into view. It may be necessary before making this examination to 
cleanse the external auditory canal with a fine cotton-wrapped probe. In 
cases of otitis media the drum above ShrapnelPs membrane may be found 
congested, reddened, and sometimes bulging slightly outward. If perfora- 
tion has already occurred, the opening may commonly be seen in the pos- 
terior quadrant. 

Prognosis. — The prognosis is, as a rule, good. This is especially true 
if the opening in the eardrum is made early in the disease. Where mas- 
toiditis occurs as a complication the prognosis is much more serious. If 
the middle-ear inflammation continues through lack of proper drainage and 
other surgical treatment, hearing may be impaired, and, in some instances, 
entirely lost. 

Prophylaxis. — In the treatment of all diseases in which otitis media 
is a common complication, earache should receive prompt and careful 
attention, and the eardrum from time to time be inspected. Children 
who have enlarged tonsils and adenoids, and who have suffered from ear- 
ache or from one attack of otitis media, should have these diseased tissues 
removed after the acute attack has subsided. 

Treatment.— Earache, which is commonly an early symptom, may some- 
times be relieved by hot irrigations of normal saline solution. This may be 
accomplished by inclining the child's head over its shoulder and intro- 
ducing into the ear a small straight glass medicine dropper attached to the 
hose of a fountain syringe. If the bag holding the hot saline solution is 
held one or two feet above the child's head, a steady stream of hot salt 
water may in this way be directed into the ear. Following this, hot flan- 
nel, hop-bags, or water bottles may be applied. If these measures fail to 
give relief, a few drops of warm paregoric may be dropped into the ear, 
and the ear plugged with warm cotton-wool. In some instances the pain 
may be so great that paregoric is indicated internally; it may be given in 
from 5- to 15-drop doses, according to age. If the earache continues, and 
especially if it be associated with fever, paracentesis should be performed, 
even though the eardrum presents little indication of the inflammation 
within. Following the incision a serous, seropurulent, or purulent dis- 
charge makes its appearance, sometimes at once; in other cases it may be 
delayed for twelve or more hours. The character of the discharge may 
depend upon the stage of the inflammation; in well-marked cases which 
have been developing for a number of days it is always purulent. During 
the acute stage the child should be confined to bed and the external audi- 
tory canal frequently irrigated with a warm mild saline antiseptic ; follow- 



MASTOIDITIS 717 

ing this the auditory canal should be dried with a cotton-wrapped probe, 
and a small roll of antiseptic gauze inserted. A piece of gauze over the 
external ear and a bandage to hold this in place complete the dressing. 
The gauze in the auditory canal absorbs the discharge and prevents irrita- 
tion and inflammation of these external parts. These details are most im- 
portant in treating cases where the discharge is irritating or where it lasts 
over a number of weeks. If the child is otherwise in good health and the 
drainage from the internal ear is satisfactory, the discharge should cease 
within a week or ten days, and complete recovery follow. In cases, how- 
ever, associated with syphilis, tuberculosis, or other forms of chronic mal- 
nutrition, the otitis media usually continues until these underlying causes 
have been removed by proper treatment. In such cases of prolonged mid- 
dle-ear suppuration there is great danger that the hearing may be impaired 
or lost. 

MASTOIDITIS 

Etiology.- — Since this condition is nearly always secondary to acute or 
chronic otitis media, its causative factors are the same as those just out- 
lined for that disease. The inflammation spreads from the middle ear 
into the mastoid cells, and causes inflammation and necrosis of these tis- 
sues. In every case of otitis media the physician should constantly be 
on the lookout for the development of a mastoiditis. 

Symptomatology. — Associated with the symptoms of an acute otitis 
media we may have, as indications of a mastoiditis, an unexplainable rise 
in temperature. That is to say, careful otoscopy may show that the open- 
ing in the drum membrane is sufficiently large for drainage, and may 
indicate that the middle ear condition is improving, and yet, notwith- 
standing these facts, a septic temperature develops, which may run to 
104° or 105 °F. some time during the day, and fall below normal at an- 
other. In another class of cases, when a free incision of the drum mem- 
brane followed by a copious discharge of pus fails to clear up the septic 
temperature, mastoiditis is to be suspected. The diagnosis is confirmed by 
finding the tissues over the mastoid slightly reddened, swollen, and tender 
to the touch. Tenderness above the tip of the mastoid can usually be 
elicited, even if other symptoms are absent. In making pressure care 
should be taken to press backward, so that the soreness which comes from 
the middle-ear inflammation will not be mistaken for that due to mastoid- 
itis. In many of these cases the swelling, pain and tenderness in the mas- 
toid region are so marked that the diagnosis can. scarcely be overlooked; 
in others, however, the onset may be so sudden and so violent that ex- 
tensive necrosis of the bone has occurred before the physician has even sus- 
pected the presence of otitis media. 

There is another group of cases very obscure and very insidious, char- 
acterized by septic temperature, which may run for weeks without there 
being any local evidence whatever of otitis media or mastoiditis. 



718 



OTITIS MEDIA AND MASTOIDITIS 



Treatment. — The treatment of the otitis media, of which the mastoid- 
itis is a complication, shonld be continned as above ontlined. Free drain- 
age from the middle ear mnst be maintained. Blood may be withdra T7 n 
from the mastoid region by leeches, and cold applications shonld be made 
with small ice-bags. By blowing out the middle ear through a catheter, 
introduced into the Eustachian tube, one can more effectually increase the 
drainage; this operation, however, can be done only in older children. If 
under these measures the septic temperature and the pain and tenderness 
do not begin to subside, the radical operation for mastoiditis becomes 
necessary. Chronic mastoiditis, which fails to yield to proper surgical 
treatment, may have as its underlying etiological factor syphilis or tuber- 
culosis. Doubtful cases of this character should be subjected to a thor- 
ough course of antisyphilitic treatment. 



SECTION XIII 

DISEASES OF THE SKIN 

CHAPTEE LXXXIV 
ECZEMA AND OTHEE SKIN DISEASES 

ECZEMA 

This is an inflammation of the skin which may manifest itself in an 
acute, subacute, or chronic form. 

Etiology. — It is more common in infancy, since the very delicate struc- 
ture of the skin at this period of life makes it especially susceptible to 
inflammation from irritants of any kind, and the unstable condition of the 
vasomotor nervous system makes it especially liable to cutaneous conges- 
tion, erythema, and inflammation from slight causes. 

Any agent, chemical, toxic, infectious, physical or mechanical, which 
irritates the skin and is sufficiently intense and prolonged, will cause ec- 
zema. It matters not whether this irritation comes from without or from 
within. 

Internal Causes. — Hereditary influences are important, since it is 
not uncommon to observe this disease in all of the children of a family, 
but the exact character of this hereditary predisposition cannot always 
be determined, but that in many instances it may be gouty or neurotic is 
beyond question. General malnutrition from such constitutional disturb- 
ances as glandular tuberculosis, syphilis, rickets, and anemia may produce 
special susceptibility to eczema. It is also stated that such reflex factors 
as diseased adenoids, adherent prepuce and dentition may be exciting fac- 
tors; the importance of reflex factors, however, has been greatly exagger- 
ated, and I have never been fully convinced that they deserve a place among 
the causative factors of this disease. The most important internal causes of 
eczema are undoubtedly autointoxications and gastrointestinal toxemias. 
Constipation, gastrointestinal indigestion, and food idiosyncrasies are im- 
portant factors in many cases. It may be a very difficult matter in an in- 
dividual case to determine the food idiosyncrasy which is producing the 
eczema. An article of food which in one child may aggravate or even 
produce an eczema will in another have no such influence. It is a fact, 
however, that overfeeding is one of the common factors in producing this 
disease. 

47 719 



720 ECZEMA AND OTHER SKIN DISEASES 

External Causes. — Among the most important of these the follow- 
ing may be noted : Irritating soaps, rough handling of the tender skin, 
perspiration, the rubbing together of juxtaposed skin surfaces, acid urine, 
chafing discharges from the intestines and other mucous membranes, irri- 
tating clothing, exposure to extremes of heat and cold, the application of 
certain drugs and chemicals, the scratching associated with parasitic 
skin diseases, and other causes that produce itching, and the inocula- 
tion of the skin with pathogenic bacteria. 

The character of the eczema depends upon the severity of the exciting 
cause producing the irritation, and its course upon the length of time that 
this cause is active. 

Symptomatology. — Inflammation of the skin is a very common disor- 
der of childhood. It usually begins as a congestion or erythema, and acute 
inflammatory changes follow, which may produce a variety of lesions. 
These acute processes may be erythematous, papular, vesicular, or pus- 
tular. These various forms may remain distinct, or they may be differ- 
ent stages of the same attack of eczema, or, in other cases, the various 
skin lesions may be more or less commingled, or at least may be present in 
different parts of the body at the same time. 

Erythema is very frequently found where opposed surfaces rub one 
another, such as the groins, the neck, and the axilla; it is also very com- 
mon on the face. It is characterized by redness, swelling, and infiltration 
of the skin, and later one of the typical forms of eczema may develop. 

Papular eczema is characterized by the presence of small red papules, 
which have a tendency to group themselves on the face and on the arms 
and legs. The surrounding skin is congested and the papules have a shot- 
like feel; as they coalesce they may produce a decided thickening of the 
skin, characterized by marked redness and extreme irritation. 

The vesicular type is characterized by the formation of large numbers 
of small vesicles, which may coalesce and produce large vesicles filled with 
a thick serum, which, as the vesicles break, is poured out and dries upon 
the surface. On the scalp this condition is known as seborrhea, and the 
whole or a portion of the hairy scalp of the infant is covered with a 
yellow or brownish scab, which is composed of the dried, yellowish exu- 
date, cast-off epithelium and hair. When this dried, scabby material is 
removed it leaves a red, raw, and weeping surface, which, after a time, is 
again covered with the same scabby exudate. A vesicular eczema of the 
face and of the arms and legs, which are also favorable sites for this dis- 
ease in childhood, is of the weeping variety, and portions of the surface 
may be covered by a thin crust which is easily removed. 

The pustular form is characterized by the presence of pustules; it may 
be an advanced stage of the vesicular variety. In this condition the pus- 
forming organisms play an important part in the pathological process. 
It may be one of the stages of seborrhea of the scalp above mentioned, and 
occurs most commonly on the hairy scalp and on the face. 

Following the acute stages above described a variety of forms may re- 



ECZEMA 721 

suit. These, however, do not represent any particular change in the patho- 
logical process, and therefore require no detailed description. Eczema 
crustosum refers to the formation of crusts such as have been already 
described. Eczema squamosum refers to a subacute variety of eczema in 
which there is a scaly formation. Eczema rubrum refers to the condition 
of the skin which occurs in vesicular and pustular eczemas, in which, 
with the removal of the crusts or scales, the superficial layers of the epi- 
thelium of the skin are also removed, and the lower and red layers are 
uncovered, leaving a raw, weeping surface. 

In all forms of eczema the inflammatory process in the skin is accom- 
panied by itching and burning. This symptom, while present in every 
form of eczema, is more aggravated in the papular form. It causes the 
child to scratch and rub the inflamed parts and thereby adds to the in- 
flammatory process, and very materially interferes with the curative treat- 
ment of this disease. 

Eczema, as a rule, produces no constitutional disturbance unless the 
greater portion of the body of the child is involved. In most cases the 
child is well nourished and continues to gain in weight and develop along 
normal lines. In those instances where constitutional, nervous, or gastro- 
intestinal disorders are associated with eczema, these conditions are a cause 
rather than an effect of the eczema. 

Diagnosis. — Eczema is to be differentiated from other inflammations 
of the skin. The greatest difficulty perhaps arises in differentiating papular 
and pustular syphilides from eruptions of the same character produced by 
eczema. In syphilis the skin eruption is more general, less acute, is asso- 
ciated with little or no itching, and other evidences of syphilis are com- 
monly present to assist in the differentiation. Xeglected scabies may 
produce a well-marked eczema. The differentiation of scabies associated 
with eczema can, as a rule, be made by the presence of the initial burrows 
and by the clinical history of the condition which corresponds in its onset 
to that of scabies. The contagious character of scabies and the presence 
of more than one case in a family may also assist in the differentiation. 

Prognosis. — The prognosis of acute eczema in infancy and childhood 
is, as a rule, good in those cases in which the physician has the cooperation 
of a conscientious mother or nurse who will faithfully carry out every 
detail of treatment. The prognosis, however, in subacute and chronic 
cases, especially if they be associated with some nutritional fault or chronic 
intestinal disturbance, is not so good. Many of these cases, in spite of con- 
scientious treatment, may continue for many months or even years. In 
these cases the disease may be greatly improved for a time, only to have 
the symptoms recur from undiscoverable causes. 

Treatment.— General Treatment. — In undertaking the treatment of 
a case of eczema, the mother or nurse must be made to understand the 
importance of the general as well as the local treatment. A careful fam- 
ily and previous personal history of the child must be obtained, in order 
to ascertain whether there is any constitutional taint, hereditary idiosyn- 



722 ECZEMA AND OTHEE SKIN DISEASES 

crasy, or local constitutional disorder on the part of the infant itself 
which may influence the eczema. 

If the infant be sturdy, fat, and well developed, a gouty or uric acid 
diathesis, if it can be established, may furnish a clue to the constitutional 
treatment. In such cases it is of the utmost importance that the infant 
should not be overfed. Its food should not contain more calories than 
necessary to maintain its nutrition. It is also of the greatest importance 
that constipation, if it exists, should be carefully overcome. This may be 
done by adding to the child's milk a sufficient quantity of saturated solu- 
tion of phosphate of soda, one-half tablespoonful perhaps, to each bottle 
or glass of milk. Milk of magnesia may be used for the same purpose. 
Alkalies, such as bicarbonate of soda and lime water, are also of value. 
Not only the quantity, but the character, of the food must be carefully 
scrutinized. It is advisable to exclude all raw fruit, such as orange 
juice, and many of these cases are materially benefited by diminishing the 
quantity of sugar taken. A sugar-free diet will, in some instances, mate- 
rially assist in bringing about a cure. Food rich in sugar, such as stewed 
prunes, is contraindicated, and it is also advisable to use as little sugar 
as possible with the cereal foods which the child may be taking. The 
"ready-to-serve" cereals, which are now so extensively used because of their 
judicious advertisement, are contraindicated. 

If the infant is suffering from some pronounced malnutrition, every 
attention must be given to ascertaining the cause of this constitutional 
disturbance and correcting it. If the child be rachitic or tuberculous, 
fresh air, cod-liver oil, and a properly selected diet are necessary to its 
cure. In every case of eczema it is absolutely necessary to give careful 
attention to the gastrointestinal canal. If anemia be present, some of the 
malt and organic iron preparations may be of value. In addition to 
these general rules it is of great importance in subacute and chronic cases 
to study the food idiosyncrasies of the individual child. Some clew to 
this may be had by inquiring into the food idiosyncrasies of other mem- 
bers of the family, and then again it may be discovered that certain foods, 
such as oatmeal, potatoes, eggs, and sweets, are followed by relapses ; when 
this is the case such foods are to be withheld until it be definitely proven 
that they do no harm. If eczema occurs in a breast-fed baby, the breast- 
milk should be analyzed, and if it be found to contain an excessive quan- 
tity of fat or protein, the diet, exercise, and general hygiene of the wet- 
nurse should be carefully regulated along the lines outlined in the chap- 
ter on Breast-Feeding. The breast-milk in some instances may be so 
modified as to materially influence the course of the eczema, but one is 
never justified in weaning an infant, if it be developing along normal 
lines, simply to cure its eczema. 

In cases that fail to yield to ordinary methods of treatment, such 
reflex causes of nervousness as eye-strain, adenoids and phimosis should be 
sought for, and if found should be removed by appropriate treatment. 
There can be no doubt but that vasomotor disturbances may aggravate and 



ECZEMA 723 

prolong an eczema; it is therefore possible that reflex factors such as 
those above named may act in this way. 

In the treatment of eczema it is of the greatest importance that the 
inflamed skin should not be irritated by frequent washings with soap and 
water, and above all that the child should be prevented from scratching 
and rubbing the inflamed areas. This is perhaps the most difficult part 
of the treatment; the pruritus is so intense in many of these cases that, 
unless the child be constantly watched, it will manage in some manner 
to temporarily relieve the itching by rubbing the inflamed parts against 
the bed-clothing, or against some portion of its body. To prevent this in 
eczema of the face and scalp, masks and bandages are so applied as to 
cover the whole inflamed surface, and at the same time the arms are in- 
cased in stiff sleeves of wicker or pasteboard, so that the child cannot reach 
the inflamed parts with its hands. Such devices in an individual case 
must be left to the ingenuity of the physician, it being understood that 
an important part of the treatment is the prevention of the scratching 
and rubbing of the inflamed skin. 

Local Applications. — Mild inflammations of an erythematous 
or papulo-erythematous type may be successfully treated by dusting 
powders, soothing lotions, compresses, and sedative ointments. Cases 
of the papulovesicular type of a severe and acute character should 
be treated with ice-cold compresses of weak, astringent, or boric acid 
solutions. 

Cases of the vesicular type, in which the vesicles have ruptured and 
the surface is oozing, should be treated with wet compresses or with oint- 
ments which contain a sufficient quantity of starch or zinc oxid to absorb 
the secretion and prevent crust formation. When the inflamed skin is 
covered with crusts, these should always be softened with olive oil and 
gently removed. This is of special importance when the hairy scalp is 
involved. Long-standing cases in which there is more or less infiltration 
of the skin should be treated by stimulating ointments or lotions contain- 
ing salicylic acid, resorcin and tar. Itching should be combated by anti- 
pruritic lotions. 

Erythema intertrigo and simple forms of acute eczema, not located 
on the hairy parts of the body, may be successfully treated by dusting 
powders of stearate of zinc, or of equal parts of oxid of zinc and starch. 
In these cases Starten's lotion is of great value. 

R Zinci oxidi § ss 

Pulv. calamine prsep 3 iv 

Glycerini 3 i 

Liquoris calcis ad § vi 

S. Shake and apply freely every three or four hours to the inflamed skin. 

Another valuable sedative and antipruritic lotion recommended by 
Heidingsf eld is as follows : 



724 ECZEMA AND OTHER SKIN DISEASES 

B Potass, sulphuret 3 ss 

Zinci sulphat. .' 3 ss 

Zinci oxidi 3 v 

Aquae calcis 3 vii ss 

Aquae dest. q. s. td § vi 

This preparation should be shaken and applied locally every four hours 
by means of an ordinary bristle brush. 

These lotions are not only sedative, but on drying they leave a coating 
of oxid of zinc over the inflamed parts. 

Ointments, on the whole, are of more value than other applications 
in the treatment of eczema; to obtain good results, however, it is of the 
utmost importance that they should be properly made, and that the ma- 
terials of which they are composed, especially the bases, should be fresh; 
if they are prepared with decomposing bases, containing fatty acids and 
other irritating materials, they may do more harm than good. The milder 
ointments used in the treatment of acute eczema should be applied on 
strips of lint or other soft material to the inflamed skin, and held there 
by appropriate bandages. In eczema of the face and scalp a well-fitting 
mask for the face, and hood for the scalp, best serve the purpose of hold- 
ing the ointment in position and preventing irritation of the part by 
scratching and rubbing. In the chronic and subacute forms of eczema, 
in which stronger and stimulating ointments may be required, it is best 
to make the application by lightly rubbing the unguent into the inflamed 
part; the degree of reaction which follows such an application will de- 
termine whether a stronger ointment is to be used; if the reaction is 
marked and the inflammation of the skin is increased by such an applica- 
tion, then the milder ointments suitable for the treatment of acute eczema 
are to be used for allaying this irritation. Hardaway and Grindon say: 
"As a routine prescription in almost all types of eczema in children, es- 
pecially eczema rubrum, the following prescription has the widest range 
of usefulness: 

B Zinci oxidi 3 i 

Pulv. amyli 3 ii 

Ung. picis liq 3 ii 

Ung. vaselini plumb, q. s. ad § i 

"In warm weather the amount of starch may be increased. In place 
of the tar, 2 or 3 minims of carbolic acid may be added to each ounce ; and, 
instead of the oxid of zinc, an equivalent quantity of boric acid. In most 
cases, however, the formula as given is the best." 

In beginning the treatment a sedative ointment should be prescribed : 

B Bismuth subnit 3 ii 

Zinci oxidi 3 ss 

Glycerini 3 iss 

Acidi carbolici ^l xx 

Vaselini ad 5 ii 



ECZEMA 725 

Hebra's formula is an excellent one in some cases: 

1$ Emplastri diachyli | i 

Vaselini § i 

Another formula of equally wide range of usefulness, very generally 
and almost universally employed in all types of eczema where there is a 
tendency toward vesiculation or oozing, is the well-known salicylated paste 
of Lassar : 

IJ Acidi salicylici grs.xxx 

Zinci oxidi 3 vi 

Starch 3 vi 

Vaselini § ii 

In cases where there is a suspected local infection of staphylococcic 
nature, either of etiologic or of incidental character, the sulphur salicy- 
lated paste of Lassar can be used with most gratifying results: 

Ifc Zinci oxidi 3 v 

Starch 3 v 

Sulphur 3 ii 

Acidi salicylici .grs.xxx 

Petrolatum 3 ii 

II all cases where itching is a more or less intolerant feature, the fol- 
lowing well-known lotion can be used in connection with other treatment: 

B Liq. carbonis 3 i 

Aquae dest § vi 

Sig. Apply every few hours to allay itching. 

In subacute eczema the following is used to remove the scales and stop 
the itching, and it may be followed by one of the milder ointments above 
given : 

Ifc Zinci oxidi 3 i 

Ung. picis liquidae 3 ii 

Ung. aquae rosae 3 ii 

Lanolini 3 iv 

The following bland paste, which dries and is easily washed off, may 
also be recommended: 

IJ Zinci oxidi 3 ii 

Pulv. amyli 3 ii 

Acidi salicylici grs. xv 

Ung. aquae rosae § i 



726 ECZEMA AND OTHER SKIN DISEASES 

In the treatment of seborrhea of the scalp the crust is to be thoroughly 
moistened with olive oil, which may be applied on strips of lint which are 
held in position by a skull cap. After twelve or twenty-four hours of such 
an application, the crust is to be carefully removed without tearing or 
irritating the inflamed skin, and the following ointment is then to be 
applied : 

. IJ Acidi salicylici $ i 

Sulphuris praecip 3 ss 

Ung. aquae rosse q-s 3 i 

URTICARIA 

Urticaria is a vasomotor neurosis, characterized by intense pruritus 
and presenting a more or less characteristic skin eruption. It is com- 
monly called hives or nettlerash. 

Etiology. — The important predisposing etiological factor is an exag- 
gerated instability or excitability of the vasomotor nervous system, which 
creates in the individual a special susceptibility on the part of this sys- 
tem to respond to the reflex, toxic and other exciting factors of this dis- 
ease. These factors by their action on the susceptible vasomotor nervous 
system produce a localized congestion of the part affected, associated with 
an edema due to serous exudation. The excitability of the vasomotor nerv- 
ous system may be hereditary, as urticaria is not infrequently a family 
affection, or it may be acquired as the result of disease, improper feeding, 
or bad hygienic surroundings. 

Urticaria in childhood is very commonly associated with gastrointestinal 
disturbances, and especially with acid fermentations from overfeeding with 
fats, starches and sugars. Certain articles of diet, such as strawberries, 
acid fruits, shell-fish, oatmeal, and preserved meats, may precipitate an 
attack without producing any apparent gastrointestinal disturbance. In- 
testinal worms, undigested food, reflex excitants, insect bites, and injury 
to the skin may be exciting causes. Diphtheria antitoxins and other 
serums may be followed by an attack of urticaria. 

Symptomatology. — Intense pruritus occurring suddenly without appar- 
ent local cause on the part of the skin is the most characteristic symptom. 
In a severe attack of acute urticaria the suffering produced by the intense 
itching may be almost unbearable; in milder cases, and fortunately these 
are much more common, the severe itching is confined to small portions 
of the body, and is of short duration. 

The Eruption. — The most common urticarial eruption in childhood 
is composed of small red papules (urticaria papulosa), which may be wide- 
ly scattered over the surface of the body or confined to one part. This 
eruption is associated with such intense pruritus that the skin is usually 
torn and injured by scratching; a complicating eczema may thus be pro- 
duced. In children the eruption may also present the appearance, as it 
so commonly does in the adult, of wheels with red circumferences and 



UETICAKIA 727 

paler centers. These wheels are elevated and the indurated and edematous 
thickening can be felt with the finger. This is the ordinary nettlerash. 
This character of eruption may be so grouped as to produce a general red- 
ness and swelling extending over a large portion of the body; when the 
face is involved the features may be distorted and the eyes closed. Earely, 
urticaria is associated with a formation of vesicles, and hemorrhages may 
occur in the wheels or papules. The pruritus and eruption may disap- 
pear from one part of the body to reappear at once in another. Even in 
acute attacks the symptoms may abate and be exacerbated from time to 
time over a period of days or weeks, but in the great majority of cases 
the attack is of much shorter duration. In the subacute and chronic 
forms of this disease the attacks may continue for weeks at a time, and 
may recur at frequent intervals from slight or undiscoverable causes. 

Urticaria of Mucous Membranes. — If the respiratory mucous mem- 
branes are attacked, coryza, sibilant bronchitis, severe dyspnea, or violent 
asthma may result. If the gastrointestinal mucous membrane is affected 
a colliquative diarrhea may occur, continue for a number of hours, and 
then subside without medical treatment. These syndromes on the part 
of the respiratory and gastrointestinal mucous membranes may be fol- 
lowed or preceded by attacks of urticaria of the skin. 

Prognosis. — In the acute forms the prognosis is good, inasmuch as the 
cause can usually be located and the symptoms readily controlled. Chronic 
urticaria may persist for years, resisting the most careful treatment. 

Treatment.- — This should be begun by a dose of castor oil or some saline 
cathartic. Following this, bicarbonate of soda should be given internally 
and carbolic acid in some form applied to the skin to relieve the itching. 

Ifc Acidi carbolic! 3 i 

Zinci oxidi § ss 

Pulv. calamine prgep 3 iv 

Glycerini | i 

Liquor calcis § vii 

The above prescription, together with the one which follows, is recom- 
mended by Hardaway and Grindon to relieve the pruritus of urticaria : 

I£ Mentholis 3 ii 

Alcoholis q. s. 

Acidi carbolici 3 ss 

Lotionis zinci oxidi comp | vi 

These lotions are to be applied freely with a soft rag. 

Bromid of potash, phenacetin, or antipyrin, in proper doses, may relieve 
the general nervous irritability and add much to the comfort of the pa- 
tient. 

The above treatment applies to the relief of the immediate attack, 
but the most important part of the treatment is yet to follow, and that 



728 ECZEMA AND OTHEE SKIN DISEASES 

pertains not alone to the satisfactory convalescence from the acute attack, 
but to the prevention of subsequent attacks. As a guide to this end the 
individual case should be carefully studied to discover the exciting causes 
of the attack and the food idiosyncrasies of the patient. If no cause other 
than general nervous irritability associated with some malnutrition is 
discovered, then the treatment should be fresh air, a carefully selected 
diet, outdoor exercise, quiet surroundings, and such tonics as the individual 
case may demand. These may include cod-liver oil, iron, or arsenic. In 
recurring urticaria it is most important that the patient should be treated 
for the underlying neurosis. In the great majority of cases, however, one 
is able to find some acute gastrointestinal disturbance, or some food 
idiosyncrasy, which has acted as the exciting cause. Following the pre- 
liminary cathartic, gastrointestinal disturbances are to be treated by a 
diet carefully selected to come within the range of the physiological di- 
gestive capacity of the individual child. As a matter of routine, oatmeal, 
orange juice, raw fruits of all kinds, shell-fish, fish, pastry, and sweets are 
to be carefully avoided. In the treatment of chronic and subacute cases 
it is of importance to remember that some of these cases respond to a 
sugar or fat-free diet, making a satisfactory recovery when the cream is 
taken off the milk and saccharin is used instead of sugar. It has been 
my custom in troublesome cases to place the child upon skimmed milk. If 
the urticaria is controlled by this diet, then from time to time other 
articles of food are carefully added, until following the giving of some 
article of food an attack of urticaria is produced. Only by some such 
careful method as this can the physician arrive at the particular food 
idiosyncrasy which may be an important factor in continuing this trouble- 
some disease. 

Certain intestinal antiseptics, such as salol, wintergreen sodium sali- 
cylate, and carbonate of guaiacol, may be of value in those cases which are 
produced by gastrointestinal toxemia. 

FUEUNCULOSIS 

Symptomatology. — This is an infectious condition characterized by 
multiple superficial abscesses of the skin involving the sebaceous glands and 
spreading to the cellular tissue. It occurs most commonly, and the ab- 
scesses are much more severe and widespread, in malnourished infants than 
in those of good physique. In normal well-developed infants with better 
powers of resistance the abscesses are smaller, fewer, and much more likely 
to be confined to the sebaceous glands. In malnourished infants the cellular 
tissue and deeper layers of the skin are involved, and the disease is much 
more widespread and yields much less readily to treatment. In the milder 
cases staphylococci, especially the staphylococcus pyogenes aureus, are the 
infecting organisms. In the more severe cases streptococci take part in 
the destructive process. The furuncles are commonly located on the scalp, 
forehead and neck, and in the severe cases may be widely disseminated over 



ERYTHEMA MULTIFORME 729 

the body. They may vary from a pea to a walnut in size, and may be 
very superficial, or may penetrate beneath the deep layers of the skin. The 
affection is not characterized by constitutional symptoms, except in rare 
instances, where it results in a general sepsis. The anemia, malnutrition, 
and general feebleness of constitution which are present in the worst cases 
are predisposing causes rather than symptoms of this disease. 

Prognosis. — This is good, except in those rare cases where a general 
sepsis follows. 

Treatment. — The underlying constitutional condition in malnourished 
children requires fresh air, careful feeding, and appropriate tonics, such 
as cod-liver oil and the malt and iron preparations. Calcium sulphid in 
%- to ^-grain doses, three times a day, is very generally recommended. 
The local treatment consists in thoroughly cleansing the skin with a warm 
bath of soap and water, and then incising the abscesses. In malnourished 
children having many large abscesses it is better not to open all of these 
at once. The abscesses are to be. carefully drained, and a second general 
bath is to be given for the purpose of cleansing the skin. Following 
this, the wounds are to be dressed with a moist antiseptic solution, such 
as 1 to 10,000 bichlorid of mercury. A mild sulphur ointment, 10 or 15 
grains to the ounce of lanolin, is a valuable remedy in the after-treatment 
of these abscesses, or Vleminckx solution may be used : 

IJ Calcis „ 3 iv as 

Sulphur floris 3 ix 

Aquae | xv 

M. Boil to one-half pint, let stand 24 hours. Filter. 

Sig. Paint locally with bristle brush once or twice a week. 

If the skin of the child is kept clean and proper attention is given to 
its general health, this treatment will in a short time result in permanent 
recovery. In the few cases, however, which resist this treatment "staphylo- 
coccus vaccine" may be used. The vaccine treatment of chronic furuncu- 
losis is followed by very good results. The autogenous vaccines are to be 
preferred in all cases, but where these cannot be had "stock vaccines" may 
be used as recommended under Vaccine Therapy. 

ERYTHEMA MULTIFORME 

This is an acute inflammatory disease of the skin, the etiology of which 
is not definitely known. It is, however, believed to be infectious. In many 
cases it is apparently closely related to, or caused by a, gastrointestinal 
toxemia. Some observers believe that the disease is at times a rheumatic 
manifestation. It is most frequently seen during the winter and spring 
months. 

Symptomatology. — An erythema appears on the extensor surfaces of 
the hands and feet, and gradually spreads upward over the arms and legs, 
and may finally extend very widely over all parts of the body. In the 



730 ECZEMA AND OTHER SKIN DISEASES 

beginning the eruption is pink or light red in color, and gradually be- 
comes a darker red. As a rule it spreads by appearing in spots along the 
line of the lymph vessels; these red spots gradually increase in size and 
coalesce with neighboring spots, producing a more or less extensive ery- 
thematous patch, which commonly has less color in the center than it has 
at the periphery. Associated with these thickened erythematous macules 
there may be papules and vesicles. This multiform eruption of macules, 
papules and vesicles is characteristic of this disease. Patches of purpura 
are occasionally seen. There is a sense of discomfort with little or no 
itching, but with slight fever and occasionally tenderness about the joints. 
Endocarditis may occur, but is an infrequent complication. Systolic mur- 
murs may be heard at the apex of the heart. 

Gastrointestinal symptoms resulting from acute indigestion and in- 
testinal toxemia are not infrequently associated with this condition. It 
must be remembered, however, that there is a form of simple erythema 
due to gastrointestinal toxemia, which is quite distinct from the condition 
here described. 

Prognosis. — This is favorable. The disease runs a benign course, ter- 
minating in recovery. 

Treatment. — If gastrointestinal disorders be present, they should be 
treated by proper diet and medicines. But even in those cases in which 
there is no evidence of intestinal disorder, the treatment should be begun 
by clearing the intestinal canal with calomel, followed by castor oil or a 
saline laxative. The child is then to be placed upon a milk and cereal diet, 
and given some preparation of salicylic acid, such as aspirin, salol, or win- 
tergreen sodium salicylate. In some instances there is little doubt but that 
these remedies exercise a favorable influence upon the course of this dis- 
ease. Sedative ointments containing 1 drachm of bismuth or 15 grains 
of oxid of zinc to the ounce of lanolin, should be used to relieve the irri- 
tation of the skin; if itching be present, 10 minims of carbolic acid may be 
added. 

CONGENITAL ICHTHYOSIS 

The etiology of this condition is unknown. It is congenital and heredi- 
tary. It occurs as a family disease, and may reappear through many 
generations. 

Symptomatology. — This rather rare condition makes its appearance 
in early infancy, and when fully developed the skin presents a very char- 
acteristic appearance. It is dry, thickened, and covered with fish-like 
scales. These horny, closely adherent flakes are hard and brittle, and 
cannot, as a rule, be removed without causing pain. The dried skin is 
broken and fissured, especially where there are folds, as in the flexures of 
the joints. This eruption is most characteristic on the body and on the 
extensor surfaces of the extremities. 

Prognosis. — This is unfavorable; there is no curative treatment for 
this disease. 



IMPETIGO CONTAGIOSA 



731 



Treatment. — The palliative treatment consists in softening and remov- 
ing the scales by sulphur and alkaline baths. Following this the irritation 
of the skin may be relieved by mild sulphur or salicylic acid ointments, 
10 or 15 grains to the ounce. Mild sedative antiseptic ointments may be 
used for softening and increasing the flexibility of the skin. 

IMPETIGO CONTAGIOSA 

Etiology— This is an inflammatory condition of the superficial layers 
of the skin produced by microorganisms. Streptococci and staphylococci 
are found, but the specific or- 
ganism of this affection is not 
at the present time definitely 
known. It is a distinctly con- 
tagious disease, characterized 
by definite lesions. It can be 
transmitted by inoculation from 
one individual to another, and 
is readily transferred from one 
part of the body to another by 
scratching. The fact, however, 
that such inoculations produce 
the same characteristic lesions 
is proof of the specificity of the 
microorganism which causes 
the disease. It may occur at 
all ages, but it is much more 
common in children than in 
adults. 

Symptomatology. — The primary eruption occurs in the form of thin 
watery vesicles, which in a short time are filled with seropurulent or 
purulent fluid. These pustules break and the exuded matter dries and 
produces a yellow scab, which is attached very loosely to the surface, and 
is surrounded by little or no redness of the skin. Crops of vesicles spring 
up around this scab, run the same course, and, as a result, a large portion 
of the face, especially about the angles of the mouth and chin, is covered 
with these yellow crusts. As the scab drops off, or when it is removed, 
the underlying skin is red and presents a raw, moist appearance. The 
eruption occurs most commonly on the lower portion of the face, and may 
be transferred from there by inoculation to other, portions of the face, to 
the hairy scalp, and to the hands. These uncovered parts are most likely 
to be infected, but other parts of the body may also be inoculated, so that 
the disease may be very widespread. At times the scabbing of the skin 
as the lesion becomes older may present circular or oval forms, the centers 
of these patches having healed. It is scarcely possible to mistake this form 
of impetigo for ordinary eczema. The manner of its spread and the uni- 




Fig. 105. — Impetigo Contagiosa. 
ingsfeld.) 



(M. Heid- 



732 ECZEMA AND OTHER SKIN DISEASES 

f ormity with which it presents the vesicle, pustule and scab should make 
the differentiation plain. 

Treatment. — The treatment of this condition is simple and very satis- 
factory. It yields very readily to mild sulphur and salicylate ointments. 
In beginning the treatment the crust should be softened with oil, lanolin, 
or vaselin, and then carefully removed. Sulphur soap may be used for the 
washing of the diseased part. 

Following the removal of the scab one of the following ointments may 
be applied: 

IJ Acidi salicylici grs. xv 

Zinci oxidi ( grs. xv 

Vaselini | i 

I£ Hydrargyri ammoniati grs. vii 

Vaselini , 3 iv 

Lanolini 3 iv 

Sig. Apply on lint. 

PEMPHIGUS NEONATORUM , 

This is an infectious disease of the skin which makes its appearance 
soon after birth. It is characterized by the appearance, between the third 
and the tenth day of life, of large vesicles or cysts varying from % to 1 
inch in size. These vesicles are filled with a cloudy serum, and the sur- 
rounding skin is usually slightly reddened. As the thin vesicles break 
the serum dries and forms a thin crust, which, on removal, leaves a red- 
dened raw surface. This eruption usually appears over the whole body, 
with the exception of the palms of the hands and the soles of the feet. 
New vesicles appear from time to time, the disease running its course 
in five or six weeks. In the great majority of cases it is benign, has no 
constitutional symptoms, and terminates in complete recovery. Occasion- 
ally, however, the disease may manifest itself in a more malignant type, 
being associated with symptoms of general sepsis. These cases are pro- 
longed, and, as a rule, terminate fatally. 

Etiology. — It is believed that pemphigus neonatorum and impetigo 
contagiosa are produced by the same contagion, the difference in the ap- 
pearance of the eruption depending upon the age of the child. In the 
newly born infant it presents the appearance of pemphigus just described, 
while in the older infant and child the clinical symptoms of impetigo are 
produced. Staphylococci and streptococci found in the two diseases are 
similar, and inoculation experiments indicate the identity of the two con- 
ditions. The specific microorganism, however, of this infection has not 
been clearly demonstrated. 

Diagnosis. — The characteristic bullous eruption of this disease, occur- 
ring as it does only during the early days of life, can be mistaken only 
for syphilitic pemphigus. In this latter condition, however, the blebs 



TINEA TONSURANS 733 

are most commonly found on the palms of the hands and the soles of the 
feet. This fact, with other symptoms of syphilis, which can always be 
found, is sufficient to make the differentiation. 

Treatment. — The great majority of the cases require little treatment. 
The skin eruptions may be treated with a dusting powder of stearate of 
zinc or mild antiseptic ointments, such as the following : 

IJ Bismuth subnit 3 i 

Acidi borici 3 ss 

Lanolini ad § ii 

Where the disease is associated with constitutional symptoms, the 
treatment is the same as that outlined for septic infection of the new- 
born. 

TINEA TONSURANS 

Tinea tonsurans, or ringworm of the scalp, is a contagious disease 
caused by a vegetable parasite. As Saboraud demonstrated, this parasite 
occurs in a variety of species which produce slightly different clinical 
syndromes. This form of tinea is confined almost exclusively to children, 
and is usually spread by direct contact; it may, however, be conveyed 
through articles of clothing 
and toilet utensils. It is very 
frequently seen in institu- 
tions and families in epi- 
demic form. 

Symptomatology. — Ring- 
worm of the scalp occurs in 
round or oval patches which 
are surrounded by a slightly 
raised and reddened ring. 
Toward the center of this 
ring the skin grows paler, 
and the hairs within the 
patch are stiff, brittle, broken 
off near the skin, and sur- 
rounded by a whitish scaly 
epithelium. The patch in- 
creases in size in all direc- 
tions graduallv nroducin^ 1 a -^ IG - 1( ^. — Alopecia Accompanying Ringworm of 
n ' • , K f ° the Scalp. (M. Heidingsfeld.) 

larger ring, which approaches 

baldness. The same child may have more than one patch of tinea, and 
these, by enlarging, may run together, producing one large irregular patch 
with rounded ends. 

Diagnosis. — The diagnosis is easily made by the presence of circular 
scaly patches having a reddened circumference and containing the dry and 
brittle hair stumps. If the roots of one of these diseased hairs be exam- 




734 ECZEMA AND OTHEE SKIN DISEASES 

ined under the microscope, after soaking it on a cover glass in a drop of 
liquor potassii, the small spores which constitute this parasite may be dis- 
covered. 

Treatment. — The treatment of this condition is entirely local, and, on 
the whole, is satisfactory, although many cases respond very slowly to 
treatment. 

The prophylactic treatment is important. Children with tinea should 
not be allowed to go to school, and in institutions they should, if pos- 
sible, be isolated from other children. Where isolation is not possible, 
every precaution should be taken against the spread of this disease by 
prohibiting diseased children from coming in close contact with the well 
ones, and by seeing that each child suffering from tinea has his own comb 
and hairbrush, and that these be frequently disinfected. All toilet articles 
and clothing used by infected children should be carefully boiled and 
washed before they are used by other children. 

In beginning the treatment the hair of the entire head should be close- 
ly cut or shaven. In girls this is not always possible, as the physician 
is requested to make an attempt to save the hair; in such cases the hair 
for half an inch around the patch of tinea should be closely cut. After 
this preparation the whole scalp is to be carefully washed with soap and 
water, and afterward with a saturated solution of boracic acid. This 
washing of the scalp with boracic acid is to be done daily throughout the 
treatment, not only to prevent the spread of the disease to other children, 
but to prevent inoculation of other portions of the scalp in the same child. 

Sulphur and salicylic acid are very valuable in the treatment of ring- 
worm. These remedies may be combined in the same prescription as fol- 
lows: 

I£ Acidi salicylici 3 ss 

Sulphuris praecip 3 i 

Vaselini | i 

Sig. Kub thoroughly into the patch morning and evening. 

This ointment is also of great value in ringworm of the body, which 
yields very readily to treatment. 

Chrysarobin is one of the most valuable of remedies in ringworm of 
the scalp. It, however, must be applied carefully to the patch and subse- 
quent applications are to be decided on by the degree of reaction which 
follows the first application. Sometimes it causes an acute eczema which 
contraindicates its use. Hutchinson, quoted by Hardaway and Grindon, 
recommends the following formula : 

B Chrysarobini 3 i 

Hydrarg. ammoniati grs. xx 

Liq. carbonis deterg ttj, x 

Lanolini 3 i 

Adipis recentis 3 vi 



SCABIES 735 

They also say the following method, recommended by Crocker, "has 
given good results in our hands." The patches, as well as a surrounding 
strip one-half inch wide, are closely shaven, after which they are painted 
with collodion containing salicylic acid, 1 to 30. Fresh collodion is ap- 
plied every day for a week. The dried collodion is then lifted off by in- 
serting a spatula under its edge, and the process repeated until a cure is 
effected. 

Heidingsfeld says an almost unfailing chrysarobin ointment, which 
should be applied exceedingly sparingly, is the following : 

IJ Acidi salicylici grs. xxx 

Acidi pyrogallici 3 i ss 

Eesorcini 3 i 

Chrysarobini 3 i ss 

Sapo viridis 3 v 

Petrolati 3 x 

Cases that do not yield satisfactorily to the above treatment should 
be treated by the X-ray; when this is properly done the disease commonly 
yields very readily. A permanent and comparatively rapid cure is effected. 

SCABIES 

Etiology. — Scabies, or the itch, is a contagious disease of the skin 
caused by the acarus scabiei (itch-mite). This parasite burrows between 
the epithelial layers of the skin, producing a thin line from % to % inch 
in length, which can readily be seen through a small magnifying glass, 
and may be made out by the naked eye. This burrow is usually slightly 
discolored with dirt, especially at its entrance, and at its end a yellowish 
opaque object (the acarus) and a pearly white vesicle may be seen.' The 
acarus may be lifted from its burrow on the point of a needle and examined 
under the microscope ; the finding of the itch-mite is absolute proof of the 
existence of scabies. The diagnosis, however, is commonly made by the 
characteristic burrows above described and by the intense itching which 
occurs early, continues throughout the disease, and is always worse at 
night. These pathognomonic burrows can be most readily found between 
the fingers and upon the wrists, feet, and buttocks of the child. Very 
commonly there is difficulty in finding them because they are obscured by 
the secondary inflammatory lesions, produced in part by the irritation of 
these parasites, but largely by the scratching and tearing of the skin, which 
are unavoidable on account of the intolerable itching. In nearly all cases a 
secondary eczema occurs, characterized by the formation of vesicles, pa- 
pules and pustules. These are lacerated by scratching, and finger-nail 
marks are added to the other lesions, and the serum and pus dry, pro- 
ducing crusts. 

Diagnosis. — In advanced cases this disease may be mistaken for ordi- 
nary eczema. When the burrows can be seen and the parasites found the 
48 



736 



ECZEMA AND OTHEE SKIN DISEASES 



diagnosis is easy. But even when this is not possible the differential diag- 
nosis between the two conditions can usually be made by the intense pru- 
ritus which charac- 
terizes scabies from 
the very beginning 
of the disease, and 
by the favorite loca- 
tions of the two con- 
ditions. A history 
pointing to contagion 
is also important. 

Treatment.— The 
treatment is simple 
and very satisfac- 
tory; sulphur applied 
in the form of an 
ointment acts spe- 
cifically in the cure 
of this disease. Be- 
fore making this 
application all per- 
sonal and bed-cloth- 
ing should be steril- 
ized to prevent reinoeulation during or following the treatment. The 
whole surface of the body should be cleansed with soap and hot water 
and, after thoroughly drying the skin, all that portion of the body on 
which there is any eruption should be carefully rubbed with sulphur oint- 
ment — 1 drachm of sulphur to 1 ounce of vaselin. This application 
should be made before going to bed, and the next morning it may be 
removed by a bath of soap and hot water, and clean clothes put on for 
the day. This treatment is to be repeated three or four nights in succes- 
sion. It may then be discontinued for a few days, and again repeated 
for two nights in succession; by this time a permanent cure is usually 
effected so far as the destruction of the acaries is concerned, but the asso- 
ciated eczema may require treatment. 




Fig. 107. 



-Pustular Scabies of the Hands. 
ingsfeld.) 



(M. Heid- 



PEDICULOSIS CAPILLITII 

Etiology. — This condition is caused by the pediculus capitis, or head 
louse, which is 1 to 2 mm. in length and has attached to its head a sharp 
proboscis through which it feeds by imbedding it in the scalp. This pro- 
duces the intense itching which is characteristic of this condition, and 
causes the child to scratch, tear, and mutilate the already irritated scalp. 
The irritation caused by the louse, together with the traumatism produced 
by the scratching, may cause an inflammation of the skin (eczema), which 
is confined to the hairy scalp. This parasite is very prolific and fastens 



PEDICULOSIS CAPILLITII 737 

its eggs in great numbers to the hairs; these may be readily seen as 
grayish- white scales rather firmly attached to the hair. They may be dis- 
tinguished from dandruff scales by the fact that they cannot be removed 
by brushing. 

The eczema produced by this condition is characterized by much more 
itching than is ordinary eczema of the scalp. The lymphatic glands in the 
occipital region are enlarged in aggravated cases. 

Treatment. — In hospital cases the hair should be closely cut; in pri- 
vate practice, however, the condition is usually discovered before a well- 
pronounced eczema has resulted, and the cutting of the hair is not neces- 
sary. 

The treatment consists in saturating the hair with coal-oil. This 
may be done by carefully rubbing it in with a cloth. When the hair is 
thoroughly soaked, a skull cap is applied covering the whole hairy scalp; 
the next morning the oil is washed out with soap and water and the hair 
dried. If the associated eczema persists, it may require treatment, but, 
as a rule, with the removal of the cause the inflammation of the skin is 
quickly cured. 

Heidingsfeld says: "It is essential for the successful treatment of 
pediculosis capillitii that one should bear in mind that the developing 
larvae are not destroyed by the antiseptics which are successful in re- 
moving insects which have been hatched. The larvae are encased in im- 
pervious keratin, and, after an interval of seven to fourteen days, there 
will be a fresh crop of new insects. These must be destroyed by a repeti- 
tion of the treatment. The larvae are attached to the hair by means of 
a calcareous cement. This is readily dissolved by ordinary vinegar or a 
ten per cent, solution of acetic acid. The live insects and the larvae, 
however, can be removed at the same time by saturating the hair with 
compresses of 1-200 bichlorid in vinegar, for six or eight hours. The 
bichlorid destroys the live insects and the larvae are loosened from the 
hair by the vinegar, so they can be readily removed by means of a fine 
comb." 



INDEX 



Abdomen, examination of, in illness, 30. 

Abscess, of brain, 617; deep bone, com- 
plicating typhoid fever, 274; of liver, 
complicating lobar pneumonia, 448; of 
lymph glands, complicating vaccinia, 
353; periesophageal, 157; perineph- 
ritic, 590; peritonsillar, 421; retro- 
pharyngeal, 427. 

Abt, on renal and vesical irritation fol- 
lowing use of urotropin, 587. 

Acarus scabiei, 735. 

Acetate of potash. See Potassium ace- 
tate. 

Acetone group, presence of, in urine, 
565; in recurrent vomiting, 255. 

Acetonuria, 565; diagnosis of, 566; eti- 
ology of, 565; in measles, 336; progno- 
sis of, 566; treatment of, 567; in ty- 
phoid fever, 273. 

Acidosis, in recurrent vomiting, 252, 255. 

Adams, report by, of recoveries from sep- 
tic endocarditis, 491. 

Adenie. See HodgMn's disease. 

Adenitis, cervical, in scarlet fever, 321; 
treatment of, 331. 

Adenitis, simple, 542; definition of, 
542; diagnosis of, 544; etiology of, 
542; microorganisms present in, 542; 
symptomatology of, 543; treatment of, 
544. 

Adenoids, 424; cough caused by, mis- 
taken for whooping cough, 291; diag- 
nosis of, 426; etiology of, 425; fre- 
quency of, 425; history of knowledge 
concerning, 424; method of examining, 
426 ; as cause of pavor noeturnus, 672 ; 
sources of infection in, 425; sympto- 
matology of, 425; treatment of, 426. 

Adenoids as portals of infection, in endo- 
carditis, 493; in acute articular rheu- 
matism, 402; in chorea, 701; in diph- 
theria, 295; in influenza, 311; in status 
lymphaticus, 545, 547. 

Adenoids, removal of, as protection 
against acute articular rheumatism, 
406; for relief of asthma, 712; as pro- 
tection against endocarditis, 493, 503 



indications for, 427; as protection 
against pericarditis, 512; for relief of 
acute rhinitis, 414; for relief of 
chronic rhinitis, 415; for relief of ton- 
sillar hypertrophy, 424; as protection 
against tuberculosis, 395. 

Adrenalin, use of, in asthmatic attacks, 
712; in epistaxis, 416; in hemophilia, 
539; in hemorrhage in new : born, 
83; in purpura hemorrhagica, 537; in 
splanchnic paralysis during diphtheria, 
307. 

Agglutinins, 55. 

Albolin, use of, in scarlet fever, 330. 

Albumin water, as artificial food, 128; 
in infantile atrophy, 201; in typhoid 
fever, 278. 

Albuminuria, 567 ; cyclic, 568 ; definition 
of, 567; forms of, 567; in influenza, 
312; in mumps, 359; in nephritis, 576; 
orthostatic, 568; physiological, 567; 
postural, 568; in purpura hemorrha- 
gica, 533 ; in purpura rheumatica, 535 ; 
in scarlet fever, 322; in septic infec- 
tion of new-born, 78; in tonsillitis, 422; 
in variola, 347; in whooping cough, 
290. 

Albuminura, toxic. See Nephritis, toxic. 

Alcohol, therapeutic use of, in broncho- 
pneumonia, 466; in acute cardiac dila- 
tation, 498; in lobar pneumonia, 450; 
multiple neuritis due to undue use of, 
661; in toxic nephritis, 574; in typhoid 
fever, 277. 

Alexins, 107. 

Alkalies, therapeutic use of in acetonu- 
ria, 567; in acute articular rheuma- 
tism, 405; in enuresis, 602; in pica, 
705. 

Alkaline diluents, 139. 

Alkaline waters, therapeutic use of, in 
cystopyelitis, 586; in eczema, 722; in 
acute nephritis, 581; in chronic ne- 
phritis, 583; in toxic nephritis, 574; 
in valvular heart disease from rheuma- 
tism, 504. 

Amaurotic family idiocy, 624. 
739 



740 



INDEX 



Ameba coll, 178. 

Amyl nitrite, use of, in epilepsy, 695. 

Amylase, in human milk, 106. 

Anaphylaxis, 185. 

Anatomic age of child, 19. 

Anderson and Frost, on the extent of 
paralysis in acute anterior poliomyeli- 
tis, 647. 

Anemia, simple, 522; due to acute ar- 
ticular rheumatism, 404, 406; blood 
picture in, 523; cause of chorea, 697; 
symptom of chorea, 700; definition of, 
522; diagnosis of, 523; due to endocar- 
ditis, 490; etiology of, 522; associated 
with habit spasm, 702; associated with 
hemophilia, 539; associated with Hodg- 
kin's disease, 541; due to malaria, 283; 
prognosis of, 524; due to purpura 
hemorrhagica, 533; associated with 
splenomegaly, 552; associated with 
sporadic cretinism, 554; symptomatol- 
ogy of, 523; due to syphilis, 366; asso- 
ciated with toxic nephritis, 572; treat- 
ment of, 524; associated with tubercu- 
losis of lymph nodes, 382; associated 
with valvular heart disease, 505. 

Anemia of infancy and childhood, 518, 
521. 

Anemia, pernicious, 528; blood picture 
in, 528; definition of, 528; diagnosis 
in, 529; etiology of, 528; symptoma- 
tology of, 528; treatment of, 529. 

Anesthesia, symptom of hysteria, 706. 

Anesthetics, danger from, in status 
lymphaticus, 550; sudden death from, 
547. 

Angina, gangrenous, in scarlet fever, 
324; ulcerative, 324. 

Angioneurotic edema, 535. 

Anisocytosis, 516. 

Anopheles, destruction of, 284; trans- 
mission of malaria by, 280. 

Anorexia nervosa, in hysteria, 707. 

Antibodies, syphilitic, 368. 

Antimeningitic serum. See Serum. 

Antipyretics, use of, in bronchopneu- 
monia, 467; in fevers, 266; in lobar 
pneumonia, 451; in scarlet fever, 329; 
in typhoid fever, 278. 

Antiserums, therapeutic use of, 59. 

Antitoxin of diphtheria, use of, in 
bronchopneumonia complicating diph- 
theria, 307; use of, in determining 
diphtheritic character of pseudo-mem- 
branous rhinitis, 413; use of, in diag- 
nosis between diphtheria and acute 
laryngitis, 432, 433; use of, in diagno- 
sis between diphtheria and tonsillitis, 



420; discovery of, 302; dose of, in hos- 
pital practice, 303; dose of, in private 
practice, 304; use of, with intubation, 
304; use of, in membranous laryngitis 
complicating measles, 340; method of 
preparing, 302; method of using, 303; 
mortality of diphtheria reduced by, 
300, 302; use of, in post-diphtheritic 
paralysis, 307; prophylactic use of, 
3C2; use of, in scarlet fever compli- 
cating diphtheria, 330; use of, in sep- 
ticemia complicating diphtheria, 307; 
skin eruptions following use of, 304; 
use of, in stomatitis gangrenosa, 153; 
use of, with tracheotomy, 304. 

Antitoxin of tetanus, 59, 91. 

Anti-typhoid inoculation, 276. 

Anuria, 560. 

Anus, atresia of, 233; fissure of, 235; 
malformation of, 233 ; spasm of, 236. 

Aortic regurgitation, 501. 

Aortic stenosis, 501. 

Aphonia, hysterical, 707. 

Appendicitis, 222 ; blood picture in, 225 ; 
conditions covered by term, 222; diag- 
nosis of, 226; etiology of, 223; indica- 
tions for operation in, 228; mortality 
from, 227; pathology of, 223; physical 
examination in, 224; prognosis of, 
227; symptomatology of, 224; treat- 
ment of, 227. 

Argyrol, local use of, in diphtheria, 304; 
in acute follicular tonsillitis, 423; in 
gonorrheal vulvovaginitis, 594; in 
scarlet fever, 330. 

Arnheim, on Eontgen-ray picture in di- 
agnosis of persistent patulous ductus 
arteriosus Botalli, 488. 

Arnold steam- sterilizer, 120. 

Arrhythmia, 506. 

Arsenic, therapeutic use of, in asthma, 
713; in acute cardiac dilatation, 498; 
in chorea, 700; in enuresis, 601; in 
Hodgkin's disease, 542; in malaria, 
286 ; as cause of multiple neuritis, 661 ; 
in pavor nocturnus, 675; in pernicious 
anemia, 529; pseudo-leukemia unaf- 
fected by, 526; in pseudo-masturba- 
tion, 609; in simple secondary anemia, 
524; toxic nephritis caused by, 573, 
575; in valvular heart disease, 505. 

Arsenic, Fowler's solution of. See 
Fowler. 

Arthritis, chronic rheumatoid, 408. 

Arthritis, chronic villous, 407. 

Arthritis deformans. See Chronic 
rheumatoid arthritis. 

Arthritis, infectious, 407. 



INDEX 



41 



Arthritis, septic, complicating scarlet- 
fever, 324. 

Artificial feeding in infancy, addi- 
tional foods in, 142; albumin water 
in, 128; alkaline diluents in, 139; 
beef juice in, 129; broths in, 129; 
buttermilk in, 122; caloric standard 
of values in, 130; cane sugar in, 125; 
carbohydrates in, 124, 135; carbohy- 
drate diluents in, 138; casein in, 135; 
cereal decoctions in, 126; cleanliness 
essential in, 133; condensed milk in, 
126; cow's milk in, 118; determination 
of accurate percentages in, 139 ; dex- 
trinized gruels in, 126; fat in, 135; 
Finkelstein 's albumin milk in, 123 ; 
food formulae in, 133; fresh air essen- 
tial to success of, 134; home modifica- 
tion of. milk in, 135; ingredients of, 
103; malted milk in, 128; maltose in, 
125; malt soups in, 124; meat prepa- 
rations in, 129; necessity for, among 
poor, 115; Nestle 's food in, 127; over- 
feeding a danger in, 133; pasteurized 
milk in, 120; peptonized milk in, 121; 
percentage of different foodstuffs in, 
134; in premature infants, 67; prin- 
ciples of, 132 ; proprietary foods in, 
127; regularity essential to success of, 
134; rest essential to success of, 134; 
Eotch laboratory method of modifica- 
tion in, 141; skimmed milk in, 124; 
sterilized milk in, 119; value of per- 
centage feeding in, 129 ; in treatment 
of whooping cough, 292. 

Artificial respiration, 72. 

Ascaris lumbricoides, 215; treatment 
of, 216. 

Ascites, 232; diagnosis of, 232; etiology 
of, 232; treatment of, in tumor of the 
kidney, 589; treatment of, in valvular 
heart disease, 506. 

Asphyxia, as cause of idiocy, 623 ; livida, 
70; pallida, 70. 

Asphyxia neonatorum, 69 ; diagnosis of, 
71; etiology of, 69; prognosis of, 71; 
prophylaxis of, 71; symptomatology of, 
70 ; treatment of, 72. 

Aspidium, use of, in tenia, 214. 

Aspiration, in pericarditis with effusion, 
513 ; in pleurisy with effusion, 479. 

Aspirin, therapeutic use of, in endocar- 
ditis, 494; in fevers, 267; in influenza, 
314; in pleurisy, 478; in tonsillitis, 
422; in tuberculosis, 400. 

ASTASIA-ABASIA, 706. 

Asthma, 710 ; definition of, 710 ; etiology 
of, 711; prognosis of, 712; symptom- 



atology, 711; thymic, 546; treatment 
of, during attack, 712; treatment of, 
during interval, 712. 

Ataxia, hereditary, 657; treatment of, 
658. 

Atelectasis, congenital, 73; etiology 
of, 74; symptomatology of, 74; treat- 
ment of, 75. 

Atrophy, muscular, in facial paralysis, 
665; in multiple neuritis, 663; in acute 
anterior poliomyelitis, 648; affecting 
the voluntary muscles, 666. 

Atropin, therapeutic use of, in asthma, 
712; in ophthalmia neonatorum, 97. 

Aura, 693. 

Auscultation, value of, in physical ex- 
amination, 34. 

Autogenous vaccines, therapeutic use 
of, 57. 

Autoinfections, a cause of headache, 
709 ; association of, with toxic nephri- 
tis, 573. 

Autotoxins, cause of eczema, 719 ; cause 
of headache, 709. 



B 



Babinski reflex, in epilepsy, 694; in 
meningococcus meningitis, 633 ; method 
of examination for, 32; in muscular 
contracture of infantile cerebral palsy, 
613 ; in tuberculous meningitis, 628. 

Bacillus : B. " blue, ' ' cause of enteric 
infection, 178; B. coli communis, see 
B. colon; B. colon, cause of cystopye- 
litis, 584; cause of enuresis, 601; cause 
of fever resembling typhoid, 267; cause 
of simple vulvovaginitis, 595; B. en- 
teriditis, cause of fever resembling ty- 
phoid, 265, 267; cause of meat-poison- 
ing, 267; B. gas, see B. Welchii; B. 
of influenza, 308, 311; cause of enteric 
infection, 178; B. Klebs-Loffler, 295; 
B. paratyphoid, cause of fever resem- 
bling typhoid, 265, 267; cause of 
meat-poisoning, 267; B. pertussis, 287; 
B. Pfeiffer, see B. of influenza; B. 
proteus, as cause of enteric infection, 
178; B. pseudo-diphtheritic, as cause 
of simple vulvovaginitis, 595; B. 
Shiga, 178; B. typhoid, 267; B. of Vin- 
cent, 419; B. Welchii, as cause of en- 
teric infection, 178. 

Bacteria, present in appendicitis, 223, 
224; present in human milk. 112; pres- 
ent in intestinal canal of infant, 176, 
177; entrance of, through umbilical 
wound in sepsis of new-born, 263. 



742 



INDEX 



Bacterial content, in cream, 133; in 
milk, 118, 119. 

Babes and Zambolovici, bacillus isolated 
by, found in gangrenous stomatitis, 
152. 

Bacterial substances. See Bacterioly- 
sins. 

Bacterial vaccines, therapeutic use of, 
55. 

Bacteriological examination, in diag- 
nosis between brain abscess and menin- 
gitis, 618; in diagnosis of diphtheria, 
301; in prophylaxis of diphtheria, 
302; in diagnosis between diphtheria 
and acute laryngitis, 432, 433; in diag- 
nosis between diphtheria and tonsillitis, 
420; in diagnosis of pleurisy with ef- 
fusion, 477 ; in diagnosis of acute polio- 
myelitis, 649; in diagnosis of tubercu- 
lar meningitis, 629. 

Bacteriolysins, 55. 

Baginsky, on frequency of nephritis as 
complication of diphtheria, 300. 

Barlow, on acute articular rheumatism, 
402; on acute articular rheumatism at- 
tacking the hip joint, 403; on infan- 
tile scurvy, 246. 

Basophiles, 517. 

Baths, alkaline, in treatment of epil- 
epsy, 696; in treatment of purpura, 
536. 

Baths, cold, objections to, in acute 
catarrhal bronchitis, 442; objections to 
in typhoid fever, 277; in treatment of 
fever in infancy, 266; in treatment of 
fever in older children, 267. 

Baths, hot, in edema of larynx, 435; in 
lobar pneumonia, 451; temperature of, 
46; therapeutic value of, 46. 

Baths, Nauheim. See Nauheim. 

Baths, salt, in treatment of rickets, 
245. 

Baths, sponge, in bronchopneumonia, 
468; in cystopyelitis, 587; in fever of 
infancy, 267 ; in lobar pneumonia, 451 ; 
in malaria, 286; in measles, 339; in 
scarlet fever, 329; in tonsillitis, 423; 
in variola, 348; temperature of, 45; 
therapeutic value of ; 45. 

Baths, tepid, in fever of infancy, 267; 
in influenza, 313; in typhoid fever, 
277. 

Baths, tub, in eclampsia, 682; in scarlet 
fever, 329; in tonsillitis, 423; objec- 
tions to, in typhoid fever, 277; tem- 
perature of, 45; therapeutic value of, 
45. 

Baths, warm, in asphyxia neonatorum, 



73; in bronchopneumonia, 468; in 
acute catarrhal bronchitis, 442; in 
chorea, 701; in acute laryngitis, 433; 
in meningococcus meningitis, 638; in 
multiple neuritis, 663; in tetany, 689; 
in toxic nephritis, 574; in tuberculous 
bronchopneumonia, 401. 

Baumler, on results of vaccination, 350. 

Becamp, discovery of amylase by, 106. 

Beck, on pneumococcus as cause of pleu- 
risy in child, 470. 

Bednar's aphtha, 154. 

Bedsores in myelitis, 654, 656. 

Beef juice, value of, in artificial feed- 
ing, 129. 

Behring, discovery of antitoxin by, 302. 

Bell, on facial paralysis, 665. 

Bell's palsy. See Facial paralysis. 

Belladonna, therapeutic use of, in 
asthma, 712; in bronchopneumonia, 
467; in acute catarrhal bronchitis, 441; 
in cough of tuberculosis, 400; in enu- 
resis, 602; in epilepsy, 696; in in- 
fluenza, 313, 314; in lobar pneumonia, 
453; in measles, 339; in pavor noc- 
turnus, 675; in pseado-masturbation, 
609; in whooping cough, 293. 

Belladonna ointment, use of, in mumps, 
360. 

Beneke, on increase in size of the heart 
during first five years of life, 484. 

Benoit, on digestive ferments present in 
human milk, 107. 

Benzoate of soda. See Sodium benzo- 
ate. 

Benzoin, compound tincture of, use of, 
by inhalations, in acute laryngitis, 433; 
in acute rhinitis, 414. 

Bernheim and Pospischill, on stomati- 
tis ulcerosa, 150. 

Bernouilli, on mortality from small-pox 
before vaccination, 349. 

Betanaphthol, in chlorosis, 528; in per- 
nicious anemia, 529; in pseudo-leuke- 
mia, 526. 

Bicarbonate of soda. See Sodium bi- 
carbonate. 

Bicarbonate of potash. See Potassium 
bicarbonate. 

Bile ducts, occlusion of, in new-born, 
93. 

Birth injuries, 97; birth palsies, 98; 
cephalhematoma, 97; facial paralysis, 
98; hematoma of the sterno-cleido-mas- 
toid muscle, 98; upper-arm paralysis, 
99. 

Birth palsies, 98. 

Bismuth subnitrate, external use of, in 



INDEX 



743 



erythema multiforme, 730 ; in syphilitic 
ulcerations, 373. 

Bismuth subnitrate, internal use of, in 
diarrhea of tuberculosis, 400, 401; in 
diarrhea of typhoid fever, 278; in en- 
teric infection, 195. 

Blackader, on prognosis ir typhoid fe- 
ver, 275; on relapses in typhoid fever, 
274. 

li Black measles/' 335. 

Blaud's pills, therapeutic use of, in 
chlorosis, 528; in purpura, 536. 

"Bleeders," 537. 

Blisters, in treatment of facial paraly- 
sis, 666; in treatment of hysteria, 708; 
contraindicated in treatment of acute 
pericarditis, 512. 

Blood, color index of, 516; diseases of, 
515; diagnostic importance of, 37; 
peculiarities of, in infancy and child- 
hood, 518; physiology of, 515; plate- 
lets of, 517; red corpuscles of, 515; 
white corpuscles of, 516. 

Blood, character of, in acute articular 
rheumatism, 404; in appendicitis, 225; 
in chlorosis, 527; in chorea, 700; in 
congenital heart disease, 486; in diph- 
theria, 297; in Hodgkin's disease, 541; 
in influenza, 310; in leukemia, 530; in 
lobar pneumonia, 447; in malaria, 284; 
in measles, 336; in meningitis, 634; in 
pernicious anemia, 528 ; in poliomyeli- 
tis, 649; in pseudo-leukemia, 525; in 
purpura, 532; in recurrent vomiting, 
254; in rickets, 242; in rubella, 343; 
in scarlet fever, 322; in simple second- 
ary anemia, 523; in status lymphati- 
cus, 547; in syphilis, 366, 368; in ty- 
phoid fever, 273; in varicella, 356; 
in variola, 347; in whooping cough, 
289. 

Blood corpuscles, red, function of, 515; 
number of, 515; origin of, 518; patho- 
logical changes in, 515; reduction of, 
in chlorosis, 526, 527; reduction of, in 
Hodgkin's disease, 541; reduction of, 
in leukemia, 530; reduction of, in per- 
nicious anemia, 528; reduction of, in 
simple secondary anemia, 523 ; varieties 
of, 515. 

Blood corpuscles, white, number of, 
516; origin of, 516; pathological 
changes in, 517; varieties of, 516. 

Blood, diseases of, 515; chlorosis, 526; 
hemophilia, 537; leukemia, 530; perni- 
cious anemia, 528; pseudo-leukemia, 
524; purpura, 531; simple secondary 
anemia, 522. 



Blumenreich, on area of dulness pro- 
duced by the thymus gland, 547. 

Boggs, on changes in area of thymic dul- 
ness, 547. 

Bokay, on frequency of retropharyngeal 
abscess in first year of life, 428. 

Bones, changes in, due to syphilis, 365, 
367; changes in, due tc tuberculosis, 
373, 381, 391; deformities of, due to 
rickets, 240; treatment of tuberculosis 
of, 401. 

Bony framework, growth and develop- 
ment of, 19. 

Booker, on proteus vulgaris as a cause 
of enteric infection, 178; on strepto- 
coccus enteriditis as a cause of enteric 
infection, 178. 

Boracic acid, as irrigating solution in 
vulvovaginitis, 594. 

Bordet and Genow, isolation of "bacil- 
lus pertussis ' ' by, 287. 

BOTHRIOCEPHALUS LATUS, 212. 

Bovaird, on primary intestinal tubercu- 
losis, 380. 

Bowditch, on measurements of growth in 
children, 17. 

Boyd, on weight of brain in early life, 23. 

Bradycardia, 507. 

Brain abscess, 617; course of, 618; di- 
agnosis of, 618; duration of, 618; eti- 
ology of, 617; situation of, 617; symp- 
tomatology of, 618; treatment of, 618. 

Brain, diseases of, 610; abscess, 617; 
amaurotic family idiocy, 624; encepha- 
loeele, 621; hydrencephalocele, 622; hy- 
drocephalus, acute, 618; hydrocephalus, 
chronic, 618; idiocy, 622; meningocele, 
621; microcephalic idiocy, 625; Mon- 
golian idiocy, 624; tumors, 616. 

Brain tumors, 616; diagnosis of, 617; 
general symptoms of, 616; local symp- 
toms of, 617; nature of, 616; position 
of, 616; treatment of, 617. 

Brandy, therapeutic use of, in broncho- 
pneumonia, 466; in acute cardiac dila- 
tation, 498; in diphtheria, 307; in 
lobar pneumonia, 450; in scarlet fever, 
329; in typhoid fever, 277. 

Branchial cysts, 158. 

Breast feeding, 112; importance of, to 
premature infant, 67; mixture of other 
food with, 114; normal method of, 
112; weaning from, 116; wet nurse for, 
117. 

Breast milk. See Milk, li u man. 

Breasts, swelling and tenderness of, as 
complication of mumps, 359. 

Breathing exercises, 53. 



744 



INDEX 



Breck, feeding tube devised by, 68. 

Brewer's method of drainage in em- 
pyema, 480. 

Bright 's disease, as complication of 
bronchopneumonia, 460; as complica- 
tion of measles, 336. See also Acute 
nephritis. 

Broadbent, on irregular fever resisting 
quinin suggesting acute endocarditis, 
490; on exaggeration of diastolic shock 
in chronic pericarditis, 514. 

Bromid of potash, use of, in asthma, 
712; in acute catarrhal bronchitis, 441; 
in bronchopneumonia, 467; in chorea, 
701; in diphtheria, 306; in enuresis, 
603 ; in epilepsy, 695 ; in influenza, 
314; in acute laryngitis, 432; in lobar 
pneumonia, 453; in measles, 339; in 
acute nephritis, 581; in pavor noctur- 
nus, 675 ; in pseudo-masturbation, 609 ; 
in typhoid fever, 2*78; in variola, 348; 
in urticaria, 727; in whooping cough, 
294. 

Bromid of soda, use of, in influenza, 
314; in measles, 339; in pavor noc- 
turnus, 675; in acute pericarditis, 
513; in poliomyelitis, 651. 

Bromids, use of, in cough of tuberculosis, 
400; in acute endocarditis, 493; in 
functional heart disorders, 509 ; in 
headache, 710; in hysteria, 708; in in- 
somnia, 677; in meningococcic menin- 
gitis, 638; in acute nephritis, 581; in 
multiple neuritis, 664; in nystagmus 
and head-nodding, 691; in purulent 
meningitis, 641; in tetany, 689; in 
thyroid intoxication, 558. 

Bronchi, foreign bodies in, 435. 

Bronchitis, acute catarrhal, 438; age as 
predisposing factor, 439; complications 
of, 440; definition of, 438; diagnosis 
of, 440 ; duration of, 440 ; etiology of, 
438 ; fever in, 439 ; microorganisms 
present in, 438; mortality from, in 
young children, 2; pathology of, 439; 
physical signs of, 440; prognosis of, 
440; prophylaxis in, 441; sources of 
infection in, 438; symptomatology of 
439; treatment of, 441. 

Bronchitis, afebrile asthmatic, 440. 

Bronchitis, chronic, 442. 

Bronchitis, membranous, 442. 

Bronchopneumonia, 454; abortive type 
of, 461 ; as complication of acute ca- 
tarrhal bronchitis, 438, 440; as f^ 
plication of congenital atelectasis, 74; 
as complication of diphtheria, 300, 
307; as complication of influenza, 312; 



as complication of measles, 336, 338; 
as complication of whooping cough, 
455; complications of, 462; counterir- 
ritation in treatment of, 468; degluti- 
tion type of, 462; diagnosis of, 463; 
dietetic treatment of, 465; etiology of, 
454; gastroenteritis followed by, 462; 
hygienic treatment of, 465; medical 
treatment of, 466; microorganisms 
present in, 454, 455; mortality from, 
464; in new-born, 461; pathology of, 
455; physical signs in, 460; poultices 
in treatment of, 468; predisposing 
causes of, 454; prognosis of, 464; pro- 
phylaxis of, 464; pulse rate in, 457; 
sources of infection in, 455; sputum 
findings in, 460; symptomatology cf, 
456; temperature curve in, 457, 458; 
treatment of, 464; treatment of during 
convalescence, 469 ; tuberculous form 
of, 386, 462; types of, 461; urine find- 
ings in, 459. 

Broths, use of, in diet of infancy, 129, 
142; in diet of typhoid fever, 277. 

Brudzinski, on proteus vulgaris in causa- 
tion of enteric infection, 178. 

Bryant's method of drainage in em- 
pyema, 480. 

Budin, on the influence of demand on 
supply in breast milk, 113. 

Buhl's disease. See Acute fatty degen- 
eration of new-born. 

Burk, measurements of growth in chil- 
dren by, 17. 

Buttermilk, use of, in artificial feeding 
of infants, 122; in chronic gastritis, 
172; in enteric infection, 194; in in- 
fantile atrophy, 201; in typhoid fever, 
277. 



Caffein citrate, for relief of headache, 
710. 

Caffein sodium benzoate, therapeutic 
use of, in acute cardiac dilatation, 
498; in diphtheria, 307; in lobar pneu- 
monia, 453; in poliomyelitis, 651; in 
scarlet fever, 330. 

Caffein sodium salicylate, hypodermic 
use of, in splanchnic paralysis of diph- 
theria, 307. 

Calcium, presence of, in milk, 104; 
uses of, to body, 105. 

Calcium salts, therapeutic use of, in 
furuneulosis, 729; in hemophilia, 540; 
in purpura, 536; in sporadic cretinism, 
556; in tetany, 689. 



INDEX 



745 



Calomel, therapeutic use of, in acido- 
uuria, 567; in acute articular rheuma- 
tism, 405 ; in combination with san- 
tonin for relief of ascaris lumbricoides, 
216; in chorea, 700; in chronic con- 
stipation, 207; in enteric infection, 
193; in erythema multiforme, 730; in 
acute gastric indigestion, 160 ; in acute 
gastritis, 162; in gastroduodenitis, 
165; in headache, 710; in influenza, 
313; in intestinal indigestion, 187; in 
lobar pneumonia, 452; in malaria, 266; 
in multiple neuritis, 663; in combina- 
tion with santonin for relief of oxyuris 
vermicularis, 218; in poliomyelitis, 
651; in purpura, 536; in recurrent 
vomiting, 258; in scarlet fever, 329; 
in syphilis externally, 373; in syphilis 
internally, 370, 371; in tetany, 689; 
in tonsillitis, 422 ; in typhoid fever, 277. 

Calomel, use of, by sublimation, in 
laryngeal diphtheria, 304. 

Caloric standard in artificial feeding 
of infants, 130. 

Camerer and Soldner, on composition of 
colostrum, 108. 

Camphor, therapeutic use of, in acute 
cardiac dilatation, 498. 

Camphorated oil, therapeutic use of, as 
counterirritant in bronchopneumonia, 
468; to bring out eruption in measles, 
340. 

Cancrum oris. See Stomatitis gangre- 
nosa. 

Cane sugar, use of, in artificial feeding 
of infants, 125. 

Cannabis indica, therapeutic use of, in 
epilepsy, 696. 

Cantharides, as cause of hematuria, 
563; as cause of toxic nephritis, 573, 
575. 

Carbohydrate diluents, 138. 

Carbohydrates, 103, 124; acid intoxica- 
tion due to deficient absorption of, 103 ; 
addition of, to skimmed milk, 124; use 
of, in artificial food, 135; indigestion 
due to deficiency of, 104; indigestion 
due to excess of, 104; food value of, 
103, 138; food value of, in acetonuria, 
565 ; food value of, in diabetes, 250, 
251; food value of, in intestinal dis- 
orders, 178; proportion of, in butter- 
milk, 122, 123; proportion of, in Fin- 
kelstein's albumin milk, 123; propor- 
tion of, in milk, 103 ; proportion of, in 
modified milk mixture, 124; skimmed 
milk in relation to, 124; symptoms of 
over-feeding with, 184, 186. 



Carbolic acid ointment, use of, in ery- 
thema multiforme, 730; in measles, 
339. 

Carbonate of potash. See Potassium 
carbonate. 

Cardiac dilatation, acute, 496; diagno- 
sis of, 496; diagnosis between peri- 
carditis and, 511; in diphtheria, 296, 
297; etiology of, 496; in influenza, 312, 
314; prognosis of, 496; prophylaxis of, 
497; treatment of, 498; in whooping 
cough, 290. 

Cardiac diseases. See under Heart. 

Cardiac compensation, acute cardiac 
dilatation due to failure of, 496; in mi- 
tral regurgitation, 499 ; in mitral steno- 
sis, 500; failure of, in chronic valvu- 
lar heart disease, 502; treatment of, 
505; tricuspid regurgitation due to 
failure of, 502. 

Cardiac murmurs. See Murmurs. 

Cardiac paralysis, in diphtheria, 299; 
in multiple neuritis, 663. 

Caries of spine. See Pott's disease. 

"Carriers:" of diphtheria, 295; of tu- 
berculosis, 373; of typhoid fever, 267, 
268. 

Cascara, therapeutic use of, in con- 
stipation, 207; in measles, 340; in 
acute nephritis, 579; in scarlet fever, 
329. 

Casein, action of alkalies on, 139; com- 
position of, 102; excess of, injurious, 
135; inability to digest, 186; propor- 
tion of, in buttermilk, 123; proportion 
of, in milk, 102. 

Castor-oil, therapeutic use of, in acute 
catarrhal bronchitis, 442; in broncho- 
pneumonia, 466; in chorea, 700; in 
eclampsia, 682; in enteric infection, 
196; in erythema multiforme, 730; in 
fever, 266; in headache, 710; in He- 
noch's purpura, 537; in acute intes- 
tinal indigestion, 187, 188; in lobar 
pneumonia, 452; in measles, 340; in 
multiple neuritis, 663 ; in poliomyelitis, 
651 ; in pseudo-leukemia, 526 ; in sto- 
matitis catarrhalis, 147 ; in stomatitis 
aphthosa, 148 ; in stomatitis myeosa, 
150; in tonsillitis, 422; in typhoid fe- 
ver, 277; in urticaria, 727. 

Castor-oil, use of, contraindicated, in 
constipation of infants, 204, 206 ; in 
acute gastric indigestion, 160; in acute 
gastritis, 162. 

Catarrh, acute nasal. See Rhinitis, 
acute. 



746 



INDEX 



Catarrhal jaundice. See Gastroduo- 

denitis. 
Cathartics, therapeutic use of, in cho- 
rea, 700; in eclampsia, 683; in ery- 
thema multiforme, 730; in headache, 
709; in lobar pneumonia, 452; in 
measles, 340; in acute nephritis, 578; 
in toxic nephritis, 574; in pavor noc- 
turnus, 675; in purpura, 536; in urti- 
caria, 727. 
Catheter, form of, for use in gonorrheal 
vulvovaginitis, 594; importance of 
sterilizing, in myelitis, 656. 
Catheterization, indications for, in in- 
fant, 559; necessity for, in myelitis, 
656. 
Cellulitis, as complication of vaccinia, 

353, 354. 
Cephalhematoma, in new-born, 97. 
Cereal decoctions, in artificial feeding 
of infants, 126, 135; as medium for 
quinin, 285; in diet of typhoid fever, 
277, 278. 
Cerebral croup. See Laryngismus 

stridulus. 
Cerebral hemorrhage, as cause of epi- 
lepsy, 692; as complication of Henoch 's 
purpura, 535. 
Cerebrospinal fluid, diagnostic value 
of, 37; in diagnosis between brain ab- 
scess and meningitis, 618; in meningo- 
coccus meningitis, 634; in poliomyeli- 
tis, 649 ; in purulent meningitis, 639 ; * 
in tuberculous meningitis, 629. 
Cerebrospinal meningitis. See Menin- 
gitis, meningococcus. 
Cestodes, intestinal, 211; ascaris lum- 
bricoides, 215; bothriocephalus latus, 
212; hymenolepis nana, 212; oxyuris 
vermicularis, 217; tenia elliptica, 213; 
tenia saginata, 211; tenia solium, 211. 
Chapin, on albuminuria in pulmonary 
disease, 572; on education of infant 
stomach, 122; on gastrointestinal dis- 
orders, as cause of toxic nephritis, 572; 
measurements of growth in children by, 
17. 
Chapin 's infant urinal, 559. 
Chart, showing temperature curve, in 
bronchopneumonia (mild), 459; in 
bronchopneumonia (severe), 460; in 
congenital malaria, 282; in empyema, 
474; in empyema, following pleurisy, 
473; in gastroenteric infection (mild), 
189; in gastroenteric infection (se- 
vere), 190; in laryngeal diphtheria 
treated with antitoxin and intubation, 
298; in lobar pneumonia in child two 



years old, 445; in lobar pneumonia in 
child four years old, 446; in lobar 
pneumonia in child ten years old, 447; 
in measles (uncomplicated), 336; in 
measles, complicated with broncho- 
pneumonia, 337, 338; in meningococcic 
meningitis in child six years old, 634; 
in pharyngeal diphtheria treated with 
antitoxin, 297; in anterior polio- 
myelitis of bulbar type, 446; in puru- 
lent meningitis in child ten years old, 
640; in scarlet fever in child six years 
old, 320 ; in scarlet fever in child 
twelve years old, 319; in tuberculous 
meningitis in child twenty months old, 
629; in typhoid fever in child two and 
a half years old, 270; in typhoid fever 
in child six years old, 271; in typhoid 
fever in child ten years old, 272; in 
typhoid fever relapse in child three 
years old, 274. 

Chart, showing, blood changes in derma- 
titis exfoliativa in new-born, 79; blood 
changes in purpura hemorrhagica, 534; 
mortality in diphtheria when treated 
with antitoxin, 303; mortality by age 
in scarlet fever, 326; ratio of increase 
in weight in dull, mediocre, and pre- 
cocious children, 16; weight in artifi- 
cially fed infants, 136; weight in 
breast-fed infants, 114. 

Cheadle, on acute articular rheumatism, 
402, 489; on relation between chorea 
and endocarditis, 697. 

Chest, palpation of, 30. 

Cheyne-Stokes respiration, in menin- 
gococcic meningitis, 633; in tubercu- 
lous meningitis, 628. 

Chittenden, analysis by, of Nestle 's 
food, 127. 

Chicken-pox. See Varicella. 

Child crowing. See Laryngismus stridu- 
lus. 

Childhood, excessive nerve activity in, 6; 
heat-dissipating mechanism in, 26; 
heat-regulating mechanism in, 25; in- 
hibitory function undeveloped in, 24; 
irritability of nervous system in, 24; 
mortality in, 1, 2; muscular develop- 
ment in, 20; nervous system in, 23; 
peculiarities of blood in, 518; rest 
essential to health in, 11; sleep in, 13; 
temperature in, easily affected, 26; 
weight important in, 13, 16. 

Chloral, therapeutic use of, in asthma, 
712; in chorea, 701; in cough of 
measles, 339 ; in cough of tuberculosis, 
400; in eclampsia, 683; in epilepsy, 



INDEX 



747 



696; in meningococcic meningitis, 638; 
in acute nephritis, 581; in purulent 
meningitis, 641; in tetanus neonato- 
rum, 92; in tetany, 689; in variola, 
348; in whooping cough, 294. 

Chloranemia, 545, 547; treatment of, 
550. 

Chlorate of potash. See Potassium 
chlorate. 

Chlorid of soda. See Sodium chlorid. 

Chloroform, inhalation of, in asthma, 
712; in chorea, 701; in diagnosis 
between laryngeal diphtheria and 
spasmodic catarrhal croup, 302; in 
eclampsia, 682; in epilepsy, 695; in 
laryngismus stridulus, 686; in acute 
laryngitis, 433; in acute nephritis, 581; 
danger from, in status lymphaticus, 
547. 

Chlorosis, 526; blood changes in, 527; 
color index of, 526; definition of, 526; 
diagnosis of, 527; diet in, 527; drugs 
in treatment of, 527; etiology of, 527; 
predisposing causes of, 527; prognosis 
of, 527; symptomatology of, 527; 
treatment of, 527. 

Cholera infantum, 192; heat as cause 
of, 262 ; hypodermic medication in, 196. 

Chorea, 696; in acute articular rheuma- 
tism, 404; cardiac murmurs in, 700; 
definition of, 696; diet in, 700; drugs 
in treatment of, 700; duration of, 698; 
endocarditis associated with, 489; eti- 
ology of, 697; exciting causes of, 697; 
general treatment of, 700; hygienic 
measures in, 701; medical treatment 
of, 700; predisposing causes of, 697; 
prognosis of, 698; symptomatology of, 
698; treatment of, 700; urine findings 
in, 700. 

Chorea minor. See Chorea. 

Chrysarobin, therapeutic use of, in tinea 
tonsurans, 734. 

Chvostek, on causation of tetany, 687. 

Chvostek's symptom, 688, 689. 

Circumcision, for paraphimosis, 597; for 
phimosis, 596, 601. 

Citrate of potash. See Potassium ci- 
trate. 

Clark, Andrew, on constipation in rela- 
tion to chorea, 527. 

Cleft palate, 156. 

Climate, influence of, in causation, of 
acute articular rheumatism, 402; of in- 
fluenza, 308; of poliomyelitis, 643. 

Climate, influence of, in treatment, of 
asthma, 713; of chorea, 701; of endo- 
carditis in rheumatic subjects, 493; of 



hemoglobinuria, 565 ; of heart disease, 
due to rheumatism, 503; of chronic in- 
fluenza, 314; of chronic nephritis, 583; 
of recurrent vomiting, 257; of tubercu- 
losis, 396, 401. 

Clouston, on difference between brain in 
childhood and maturity, 23. 

Clubbed fingers, in congenital heart 
disease, 486. 

Coal-oil, therapeutic use of, in pediculo- 
sis capillitii, 737. 

Coal-tars, use of,, contraindicated, in 
chronic headache, 710; in lobar pneu- 
monia, 451; in thyroid intoxication, 
558; in typhoid fever, 278. 

Codein, therapeutic use of, in cough of 
influenza, 314; in cough of measles, 
339; in lobar pneumonia, 453; in pleu- 
risy, 478; in paroxysms of whooping 
cough, 294; in tumor of kidney, 589; 
in variola, 348. 

Cod-liver oil, therapeutic use of, in acute 
articular rheumatism, 406; in asthma, 
713; in chronic bronchitis, 442; in 
chorea, 701; in constipation, 207; in 
convalescence from bronchopneumonia, 
469 ; in convalescence from influenza, 
315; in convalescence from acute laryn- 
gitis, 433; in convalescence from lobar 
pneumonia, 453; in enuresis, 601; in 
facial paralysis, 666; in laryngismus 
stridulus, 686; in multiple neuritis, 
664; in nystagmus and head-nodding, 
691; in pavor nocturnus, 675; in 
pseudo-masturbation, 609; in rickets, 
244; in scurvy, 250; in simple second- 
ary anemia, 524; in status lymphati- 
cus, 550; in tetany, 689; in tuberculo- 
sis, 399. 

Coit, on examination of milk, 118. 

Collargolum, therapeutic use of, in scar- 
let fever, 330; in ulcerative endocardi- 
tis, 494; method for, 331. 

Collargum, suppositories of, 52. 

COLLES' LAW, 361. 

Collodion, flexible, use of, in adenitis, 
544; in adenitis in scarlet fever, 331; 
in tinea tonsurans, 735. 

Cold, exposure to, a cause of hemoglo- 
binuria, 565; of nephritis, 575. 

Cold baths. See Baths. 

Cold compress. See Compress. 

Cold packs. See Packs. 

Coli vaccine, therapeutic use of, 59. 

Colon bacillus, as cause, of cystopyeli- 
tis, 584; of enuresis, 601; of fever re- 
sembling typhoid, 267; of simple vul- 
vovaginitis, 595. 



748 



INDEX 



Colon, congenital dilatation of, 208; 
etiology of, 208; prognosis of, 209; 
symptomatology of, 209; treatment of, 
209. 

Color index of blood, in chlorosis, 526; 
in pernicious anemia, 528; in simple 
anemia, 523; significance of, 516. 

Colostrum, 107. 

Coma, in acetonuria, 566; in meningococ- 
cic meningitis, 633; in acute nephritis, 
576; in purulent meningitis, 639; in 
tuberculous meningitis, 628. 

Comby, on antitoxin in post-diphtheritic 
paralysis, 307; on congenital mumps, 
358; on relapses in typhoid fever, 274; 
on respiratory manifestations in lithe- 
mia, 711. 

Compensation, cardiac. See Cardiac. 

Compound licorice powder, 579. 

Compress, cold, 46; hot, 46. 

Condensed milk. See MilTc. 

Condylomata, in hereditary syphilis, 
364. 

Congenital hypertrophy of the py- 
lorus, 166; diagnosis of, 168; etiology 
of, 166; pathology of, 166; prognosis 
of, 169; symptomatology of, 167; 
treatment of, 169. 

Congenital ichthyosis, 730; treatment 
of, 731. 

Conjunctival tuberculin test. See 
Tuberculin. 

Conjunctivitis, in gonorrheal vaginitis, 
593; in influenza, 312; in measles, 338; 
in acute rhinitis, 413. 

Connors, J. F., on food percentages, 139. 

Consanguinity, relation to, in parents 
to congenital idiocy, 623. 

Constipation, in appendicitis, 224; in 
congenital dilatation of the colon, 208; 
in congenital hypertrophy of pylorus, 
167; in enteric infection, 191; associ- 
ated with enuresis, 603; due to Finkel- 
stein's albumin milk, 124; in chronic 
gastritis, 171; in gastroduodenitis, 
165; in icterus neonatorum, 94; in in- 
testinal indigestion of infants, 198 ; in 
intestinal indigestion of older children, 
202 ; in malaria, 286 ; in peritonitis, 
231 ; in recurrent vomiting, 253 ; rec- 
tal suppositories in treatment of, 206; 
in sporadic cretinism, 554; due to ster- 
ilized milk, 120; in typhoid fever, 272; 
treatment of, in typhoid fever, 278. 

Constipation, chronic, 204; diagnosis 
of, 205; dietetic causes of, 204; die- 
tetic treatment of, in first year, 206; 
dietetic treatment of, in second year, 



207; etiology of, 204; medical treat- 
ment of, 207; symptomatology of, 205; 
treatment of, in infancy, 206; treat- 
ment of, in older children, 207. 

Convulsions, in cystopyelitis, 585; in 
epilepsy, 694; in hemiplegia, 612; in 
malaria, 284; in uremia, due to acute 
nephritis, 576. 

Coryza, acute, see Acute rhinitis; danger 
from, in infancy, 6; in influenza, 310; 
treatment of, in influenza, 313; recur- 
rent, 258; syphilitic, 362, 363. 

Cough, character of, in bronchopneumo- 
nia, 457; in acute catarrhal bronchitis, 
439; in influenza, 311; in laryngeal 
diphtheria, 298; in acute laryngitis, 
430; in lobar pneumonia, 447; in 
measles, 334 ; in pleurisy, 473 ; in retro- 
pharyngeal abscess, 428; in acute rhi- 
nitis, 413; in enlarged thymus, 546; in 
tuberculosis, 400; in whooping cough, 
289. 

Cough syrups, contraindicated, in acute 
bronchitis, 441; in bronchopneumonia, 
467. 

Councilman, on ' ' cytorrhyctes variolae, ' ' 
345; on vesicular fluid in chicken-pox, 
356. 

Counterirritation, use of, in broncho- 
pneumonia, 468; in facial paralysis, 
666; in lobar pneumonia, 451; objec- 
tions to, in acute pericarditis, 512; in 
chronic pericarditis, 513; in pleurisy, 
478. 

Coutts, on night-terror, 673, 674. 

Cowan, on mortality from small-pox be- 
fore vaccination, 350. 

Cow's milk. See Milk. 

Cow-pox. See Vaccinia. 

Crandall, on congenital malaria, 281; on 
infantile scurvy, 246; on vaccination, 
349. 

Cream, as source of fat in artificial feed- 
ing, 135; use of, in constipation, 206; 
percentage of, in modified milk, 137. 

Cream mixtures, furnished by Walker- 
Gordon Laboratories, 141; objections 
to use of, in constipation, 206; injury 
due to excess of, 186. 

Creosote, therapeutic use of, in chronic 
bronchitis, 442; in convalescence from 
bronchopneumonia, 469 ; in lobar pneu- 
monia, 452; in tuberculosis, 398; by in- 
halation in measles with septic com- 
plications, 340. 

Cresolin, inhalations of, in rhinitis, 414; 
in whooping cough, 293. 

Cretinism, endemic, 553. 



INDEX 



749 



Cretinism, sporadic, 552; definition of, 
553 ; diagnosis of, from Mongolian 
idiocy, 554; diagnosis of, from thyroid 
insufficiency, 555 ; etiology of, 553 ; 
prognosis of, 555; treatment of, 555; 
varieties of, 552. 

Crocker, on treatment of tinea tonsurans, 
735. 

Croup, cerebral, see Laryngismus stridu- 
lus; false, see Acute laryngitis; mem- 
branous, see Laryngeal diphtheria. 

Croupous pneumonia. See Lobar pneu- 
monia. 

Croup tent, use of, in acute laryngitis, 
433. 

Curvature of spine, in school children, 
19; in sporadic cretinism, 554. 

Cyanosis, in bronchopneumonia, 458; 
following cerebral injury at birth, 612; 
in congenital heart disease, 485; in 
diagnosis between broncho- and lobar 
pneumonia, 464; in edema of the 
larynx, 434; in acute laryngitis, 431; 
in multiple neuritis, 663; in myocardi- 
tis, 495; oxygen for relief of, 488; in 
paroxysmal hemoglobinuria, 565; in 
pericarditis, 510; in premature infants, 
65; in stenosis of pulmonary artery, 
487; in thyroid enlargement, 546; in 
valvular heart disease with failing 
compensation, 502. 

Cyclic albuminuria. See Orthostatic al- 
buminuria. 

Cystitis, as complication in myelitis, 656. 

Cystopyelitis, 583 ; age as predisposing 
factor in, 584; definition of, 583; diag- 
nosis of, 585; drugs in treatment of, 
587; etiology of, 584; microorganisms 
present in, 584, 586; mortality from, 
586; operative treatment for, 587; 
prognosis of, 586; prophylaxis of, 586; 
recurrent vomiting in, 585; sex as pre- 
disposing cause of, 584; sources of 
infection in, 584; symptomatology of, 
585; temperature range in, 585; ter- 
mination of, 586; treatment of, 586; 
tumor in, 585; urine findings in, 586; 
X-ray picture in, 586, 587. 

1 ' Cytorrhyctes variola," 345. 

Czerny, on hydrocephalus and diseases of 
adrenals, 619 ; on over-feeding a cause 
of intestinal indigestion, 1 74, 175 ; on 
over-feeding injurious to metabolism, 
175 ; on symptom group in acute in- 
testinal indigestion, 184. 



Dactylitis, 393. 



Deafness, due to adenoid growths, 425; 
following use of Flexner serum, 638 ; 
following meningococcic meningitis, 
635; due to mumps, 359; due to syph- 
ilis, 367. 

Death, causes of, in infancy and child- 
hood, 1. 

Debility, general, nursing infant contra- 
indicated by, 112. 

Defective interventricular septum, 
487. 

Deglutition pneumonia, 462. 

Dentition, delayed, as a pathological 
factor, 145; first, as a cause of intes- 
tinal disturbances, 176. 

Dermatitis, in new-born, 79; treatment 
of, 80. 

Dermatitis exfoliativa, 79. 

Desquamation, in measles, 336; in scar- 
let fever, 322, 327; in variola, 347. 

Dew's method of artificial respira- 
tion, 73. 

Dextrin, combination of, with maltose in 
artificial food, 125. 

Dextrinized gruels, use of, in artificial 
feeding, 126. 

Diabetes mellitus, 250; toxic nephritis 
associated with, 572. 

Diacetic acid, presence of, in urine in 
acetonuria, 565; presence of, in urine 
in measles, 336; test for, with ferrous 
chlorid, 566. 

Diarrhea, in cholera infantum, 192 ; in 
enteric infection, 191; in acute intes- 
tinal indigestion, 183, 186; in chronic 
intestinal indigestion, 198; in miliary 
tuberculosis, 387; in peritonitis, 231; 
in tuberculosis of lymph-nodes, 383; 
treatment of, in tuberculosis, 400 ; in 
typhoid fever, 272, 278. 

DlAZO REACTION of Ehrlich, 273, 275, 
336; absence of, in rubella, 343. 

Dickie, operation by, for obstruction of 
esophagus, 158. 

Diet, as a means of controlling putre- 
factive processes in intestinal canal of 
infants, 177. 

Diet, errors in, a cause, of constipation, 
204, 206; of edema, 578; of acute gas- 
tric indigestion, 159; of recurrent 
vomiting, 251; of rickets, 237; of 
scurvy, 246. 

Diet, therapeutic value of, in acute artic- 
ular rheumatism, 405, 406; in appendi- 
citis, 227; in bronchopneumonia, 465; 
in chlorosis, 527 ; in chorea, 700 ; in eon- 
genital hypertrophy of pylorus, 170; in 
constipation, 206, 207; in diabetes, 



750 



INDEX 



250; in dilatation of the stomach, 164; 
in diphtheria, 307; in eclampsia, 684; 
in eczema, 722; in edema of glottis, 
435; in acute endocarditis, 493; in 
enteric infection, 193; in erythema 
multiforme, 730; in first year of life, 
142; in fourth to sixth year of life, 
143; in functional heart disease, 508; 
in acute gastric indigestion, 160; in 
acute gastritis, 162; in chronic gas- 
tritis, 172; in gastroduodenitis, 166; 
in infantile cerebral palsies, 615; in 
acute infectious disease, as prophylaxis 
against nephritis, 578; in acute intes- 
tinal indigestion, 188; in chronic intes- 
tinal indigestion of infants, 200; in 
chronic intestinal indigestion of older 
children, 203; in lobar pneumonia, 450; 
in malaria, 286 ; in measles, 339 ; in 
meningoeoccic meningitis, 638; in mul- 
tiple neuritis, 663; in mumps, 360; in 
acute nephritis, 580; in chronic ne- 
phritis, 583 ; in nystagmus and head- 
nodding, 691; in obscure fevers, 
266; in orthostatic albuminuria, 570; 
in pavor nocturnus, 675; in acute 
pericarditis, 512; in peritonitis, 231; 
in pica, 705; in purpura, 535; in re- 
current vomiting, 257; in rickets, 243; 
in scarlet fever, 329; in scurvy, 249; 
in second year of life, 143; in simple 
secondary anemia, 527; in status 
lymphaticus, 550; in stomatitis aph- 
thosa, 148; in stomatitis catarrhalis, 
147; in stomatitis mycosa, 150; in 
syphilis, 369; in tetany, 689; in third 
year of life, 143; in tonsillitis, 423; 

. in tuberculosis, 397; in tuberculous 
peritonitis, 401 ; in typhoid fever, 
276; in urticaria, 728; in valvular dis- 
ease of the heart, 504; in varicella, 
357; in variola, 348; in whooping- 
cough, 292. 

Digestive ferments, 125 ; in milk, 106. 

Digital examination, 30. 

Dilatation of stomach, 163; diagnosis 
of, 163; etiology of, 163; prognosis of, 
164; symptomatology, 163; treatment, 
164. 

Diluents, alkaline, 139; carbohydrates, 
138. 

Diphtheria, 295; antitoxin in treatment 
of, see Antitoxin; bacillus of, 295; ba- 
cillus of, in cystopyelitis, 584; blood 
picture in, 297; "carriers" of, 295; 
complications of, 299; course of, 300; 
diagnosis of, 301; diagnosis between, 
and spasmodic catarrhal croup, 301; 



diet in, 307; drugs in, 307; duration 
of, 300; etiology of, 295; of the eye, 
299; immunity from, 295; incubation 
period of, 296 ; intubation in, 304, 305 ; 
of larynx, 297; local treatment of laryn- 
geal form, 304; measles complicated 
by, 338; mortality from, 2, 300; 
multiple neuritis due to, 299; myo- 
carditis as complication of, 299; 
paralysis following, 299, 307; pathol- 
ogy, 296; predisposing causes of, 295; 
prognosis of, 300; prophylaxis in, 302; 
quarantine in, 302; septicemia as com- 
plication of, 299, 307; symptomatology 
of, 296; temperature curve in, 297; toxe- 
mia in, 299; tracheotomy in, 304; 
transmission of, 295; of vulva, 299. 

Diplegia, 614; treatment of, 615. 

Diuretics, use of, in pleurisy with ef- 
fusion, 478; contraindicated in acute 
nephritis, 581. 

Discharges, gastrointestinal in new- 
born, 3 ; from intestinal tract in intus- 
susception, 220. 

Diuretin, use of, in pleurisy with ef- 
fusion, 478. 

Douche, nasal, 48. 

Dropsy. See Ascites and Edema. 

Drugs, effect of, upon milk of nursing 
mother, 112; hematuria caused by, 
563; hemoglobinuria caused by, 564; 
purpura caused by, 532; toxic nephri- 
tis caused by, 573; suited for use by 
inunction, 42 ; suited for use by mouth, 
38. 

Drugs, employed in treatment of, acute 
articular rheumatism, 405; of asthma 
during attack, 712; of asthma during 
interval, 713; of bronchopneumonia, 
466; of acute catarrhal bronchitis, 
441; of acute cardiac dilatation, 498; 
of chlorosis, 528; of chorea, 700; of 
congenital dilatation of colon, 210; of 
congenital icthyosis, 731; of constipa- 
tion, 207; of dilatation of stomach, 
164; of diphtheria, 307; of eclampsia, 
683; of eczema, 723; of acute endo- 
carditis, 494; of enteric infection, 
195; of enuresis, 602; of epilepsy, 
696; of functional heart disease, 508; 
of furunculosis, 729; of acute gastric 
indigestion, 160; of acute gastritis, 
162; of chronic gastritis, 173; of gas- 
troduodenitis, 165; of headache, 710; 
of hemophilia, 539; of influenza, 315; 
of intestinal indigestion in infants, 201 ; 
of intestinal indigestion in older chil- 



INDEX 



751 



dren, 203; of acute laryngitis, 432; 
of lobar pneumonia, 452; of measles, 
339; of multiple neuritis, 664; of 
mumps, 360 ; of acute nephritis, 579 ; 
of pericarditis, 513; of pernicious 
anemia, 529; of pleurisy, 478; of 
poliomyelitis, 651; of pseudo-mastur- 
bation, 609 ; of rachitis, 244 ; of re- 
current vomiting, 256; of acute rhini- 
tis, 414; of simple anemia, 524; of 
sporadic cretinism, 556; of status 
lymphaticus, 550; of stomatitis aph- 
thosa, 148; of stomatitis catarrhalis, 
147; of stomatitis ulcerosa, 151; of 
syphilis, 370; of tinea tonsurans, 734; 
of tonsillitis, 422; of tuberculosis, 398; 
of urticaria, 727; of valvular heart 
disease, 504; of variola, 348; of 
whooping cough, 294. 

Dry cupping, in treatment of acute 
nephritis, 580. 

Duchenne-erb's palsy. See Upper- 
arm paralysis. 

Ductless glands, enlargement of, in 
status lymphaticus, 545. 

Dunn, on favorable influence of lumbar 
puncture in tuberculous meningitis, 
629; on value of cerebrospinal fluid 
in diagnosis of tuberculous meningitis, 
629. 

Dwarfishness, association of, with 
endemic cretinism, 553; with sporadic 
cretinism, 553, 554; with concealed 
tuberculosis, 383. 

Dyspnea, presence of, in aeetonuria, 
566; in asthma, 711; in broncho- 
pneumonia, 457, 458; in acute ca- 
tarrhal bronchitis, 440; in congenital 
dilatation of colon, 209; in congenital 
heart disease, 485; in congenital 
laryngeal stridor, 437; in edema of 
larynx, 434; in acute endocarditis, 
490; in Hodgkin's disease, 541; in 
laryngeal diphtheria, 299; in acute 
laryngitis, 430, 431; in multiple neuri- 
tis, 663; in myocarditis, 495; in peri- 
carditis, 510; in periesophageal ab- 
scess, 158; in pleurisy, 473; in retro- 
pharyngeal abscess, 428; in status 
lymphaticus, 545, 546; in tuberculous 
bronchopneumonia, 462; in tubercu- 
losis of bronchial lymph-nodes, 382; 
in tuberculosis of mesenteric lymph- 
nodes, 383. 

Dystrophy, progressive muscular, 666. 

E 

Earache, due to adenoid growths, 425; 
49 



due to otitis media, 715, 716; fever 
associated with, 262, 263, 264; signifi- 
cance of, in bronchopneumonia, 463. 

Eberth, description of typhoid bacillus 
by, 267. 

Eclampsia, 678; definition of, 678; diet 
in, 684; due to epilepsy, 680; etiology 
of, 678; exciting causes of, 680; hys- 
terical form of, 707; idiocy due to, 
623; predisposing causes of, 678; 
prognosis of, 681; reflex causes of, 
680; symptomatology of, 680; treat- 
ment of, 682. 

Eczema, 719; crustosum, 721; definition 
of, 719; diagnosis of, 721; diet in, 
722; etiology of, 719; external causes 
of, 720; general treatment of, 721; 
internal causes of, 719; local applica- 
tions in, 723 ; papular form of, 720 ; 
prognosis of, 721; pustular form of, 
721; rubrum, 721; squamosum, 721; 
symptomatology of, 720 ; treatment of, 
721. 

Edebohls' operation, for splitting cap- 
sule of kidney, 583. 

Edema, of glottis, see Edema of larynx; 
idiopathic form of, 578; of larynx, 
434; in acute nephritis, 576, 578; in 
tetany, 688. 

Edema, localized, in Henoch's purpura, 
534; in purpura rheumatica, 535. 

Edsal, on bicarbonate of soda in recur- 
rent vomiting, 256. 

Egg albumin, use of, in artificial feed- 
ing of infants, 137. 

Eggs, soft-boiled, in diet of infants, 
142; in diet of typhoid fever, 277. 

Ehrlich's diazo-reaction. See Dia~o- 
reaction. 

Ela, on manipulations in artificial res- 
piration, 73. 

Electric heaters, use of, in acute neph- 

. ritis, 580. 

Electricity, therapeutic use of, in eon- 
genital dilatation of colon, 210; in 
facial paralysis, 666; in hysteria, 708; 
in multiple neuritis, 664; in poliomye- 
litis, 652 ; in post-diphtheritic paraly- 
sis, 309 ; in progressive muscular atro- 
phy, 669. 

Emetic, value of, in acute laryngitis, 
432. 

Emphysema, association of, with asth- 
ma, 712; with whooping cough, 289. 

Empyema, bilateral, 481; Brewer's 
method of drainage in, 4S0; Bryant's 
method of drainage in, 480; broncho- 
pneumonia complicated by, -162; 



752 



INDEX 



chronic form of, 481; pathology of, 
471 ; pneumococcus in causation of, 
470; respiratory capacity diminished 
in, 471; surgical treatment of, 479; 
temperature curve in, 472; treatment 
of, during convalescence, 482. 

Encephalitis, a cause of idiocy, 623. 

Encephalocele, 621. 

Endocarditis, acute, 489; in acute 
articular rheumatism, 404; in chorea, 
697; definition of, 489; diagnosis of, 
492; diet in, 493; drugs in treatment 
of, 493 ; etiology of, 489 ; in erythema 
multiforme, 730; in fetal life a cause 
of congenital heart disease, 485 ; hered- 
ity in causation of, 489 ; in He- 
noch 's purpura, 534; in lobar pneu- 
monia, 448; microorganisms present in, 
490; pathology of, 490; physical signs 
of, 491; prognosis of, 492; prophy- 
laxis of, 492; recurrent attacks of, as- 
sociated with rheumatism, 503; septic 
form of, 491; sources of infection in, 
490; symptomatology of, 490; tem- 
perature curve in, 490; tonsillitis as- 
sociated with, 422; treatment of, 493; 
ulcerative form of, 494. 

Enemata, high, for relief, of eclampsia, 
683 ; of intestinal intussusception, 222 ; 
of oxyuris vermicularis, 218; of re- 
current vomiting, 256. 

Enemata, rectal, in congenital dilata- 
tion of colon, 210; in chronic constipa- 
tion, 207; in acute intestinal indiges- 
tion, 187; in chronic intestinal in- 
digestion, 203; in measles, 340; in 
peritonitis, 232; therapeutic value of, 
51; in tuberculous peritonitis, 401; 
in typhoid fever, 278. 

Enteric infection, 189; cholera infan- 
tum a form of, 192; definition of, 
189; diarrhea in, 191; diet in, 193; 
drugs in, 195; hygienic treatment of, 
197; medicinal treatment of, 195; 
nervous symptoms in, 192; pathology 
of, 189; prognosis in, 193; stimulating 
treatment of, 196; symptomatology of, 
190; temperature curve in, 190, 192; 
treatment of, 193. 

Enuresis, 598; belladonna in treatment 
of, 602; diet in treatment of, 601; 
drugs in treatment of, 602; etiology 
of, 599; exciting causes of, 599; fac- 
tors in, 598, 599; general treatment of, 
601; habit in causation of, 599; hered- 
ity in causation of, 599; malnutrition 
in causation of, 599 ; medicinal treat- 
ment of, 602; physiology of, 598; pre- 



disposing causes of, 599; prognosis of, 
601; reflex irritation as cause of, 599, 
601; symptomatology of, 601; treat- 
ment of, 602; urine findings in, 601. 

Environment, as cause, of hysteria, 
706; of masturbation, 606; of pseudo- 
masturbation, 606. 

Enterocolitis, association of, with 
scurvy, 248; as complication of influ- 
enza, 310; as complication of measles, 
338; as complication of whooping- 
cough, 290; diagnosis between, and in- 
testinal intussusception, 221; See also 
Enteric infection. 

Enteritis, as complication of diphtheria, 
300. 

Epilepsy, 691; aura in, 693; convulsions 
in, 694; definition of, 691; diagnosis 
of, 694; diet in, 695; diplegia a cause 
of, 614; drugs in treatment of, 
696 ; eclampsia due to, 680 ; etiology 
of, 691; hemiplegia associated with, 
613; idiocy due to, 623; loss of con- 
sciousness in, 693; meningeal hemor- 
rhage a cause of, 611; mental symp- 
toms of, 694; number of attacks in, 
6913; prognosis in, 694; pseudomastur- 
bation not related to, 607; sugges- 
tion in treatment of, 696; surgical 
treatment of, 696; symptomatology of, 
692; treatment of, 695; types of, 692. 

Epispadias, 598. 

Epistaxis, 415; in adenoid disease, 425; 
etiology of, 415; in leukemia, 530; in 
mumps, 359; predisposing causes in, 
415; in purpura hemorrhagica, 533; 
treatment of, 416; in typhoid fever, 
273. 

Epsom salts. See Magnesium sulphate. 

Erb, on causes of tetany, 687. 

Erb's juvenile type of progressive mus- 
cular atrophy, 668. 

Erb's symptom, 688, 689. 

Ergot, purpura due to, 532. 

Eruption, character of, in acute articular 
rheumatism, 404; in congenital ichthy- 
osis, 730; from diphtheritic antitoxin, 
304; in eczema, 720; in erythema in- 
fectiosum, 343; in erythema multi- 
forme, 730; in Henoch's purpura, 534; 
in impetigo contagiosa, 731; in in- 
fluenza, 310, 311; in measles, 335; in 
meningococcic meningitis, 634; in 
pemphigus neonatorum, 732; in pur- 
pura, 531; in purpura fulminans, 532; 
in purpura hemorrhagica, 533 ; in pur- 
pura rheumatica, 535; in purpura sim- 
plex, 532; in rubella, 342; in scabies, 



INDEX 



735; in scarlet fever, 321; in sympto- 
matic purpura, 532; in syphilis, 363, 
364; in tinea tonsurans, 733; in urti- 
caria, 726; in varicella, 355; in vari- 
ola, 346. 

Eruption, following use of diphtheritic 
antitoxin, 304; following influenza, 
310, 311; method of bringing out in 
measles, 340 ; of pemphigoid type as 
complication of measles, 338. 

Erysipelas, in new-born, 80; as com- 
plication of vaccinia, 353. 

Erythema, combined with eczema, 720; 
combined with Henoch's purpura, 534; 
combined with purpura rheumatica, 
535. 

Erythema infectiosum, 343. 

Erythema multiforme, 729; treatment 
of, 730. 

Erythroblasts, 515. 

Erythrocytes. See Bed blood corpus- 
cles. 

Escherich, on "blue" bacillus in 
epidemic of enteric infection, 178; on 
colon bacillus as exciting cause of 
cystopyelitis, 584; on predisposing 
causes of tetany, 687; on streptococcus 
enteriditis in epidemic of acute enteric 
infection, 178; description of erythema 
infectiosum by, 343. 

Escherich and Moser, reduction of 
mortality in scarlet fever by, through 
use of Moser 's serum, 330. 

ESOPHAGITIS, 157. 

Esophagus, congenital malformation of, 
158. 

Ether, hypodermic use of, in diphtheria, 
307. 

Ethmoidal sinuses, brain abscess due 
to septic infection of, 618; infection 
of, in diphtheria, 300; infection of, in 
influenza, 312. 

Eucalyptus, use of, as spray in scarlet 
fever, 330. 

Eucalyptus oil, inhalation of, in 
measles with septic complications, 
340; local use of, in influenza, 314. 

Euquinin, therapeutic use of, in influ- 
enza, 313; in lobar pneumonia, 452; 
in malaria, 285; in acute rhinitis, 415; 
in whooping-cough, 293. 

Examination of sick child, 28; by 
auscultation, 32; of blood, 37; of 
cerebrospinal fluid, 37; digital form 
of, 30 ; of extremities, 31 ; family his- 
tory, 28 ; by inspection, 29 ; by palpa- 
tion, 30; by percussion, 32; physical, 
29; previous medical history, 28; of 



reflexes, 31; by Kontgen rays, 38; of 
spinal column, 31; of stools, 32; for 
tuberculosis, 54; of urine, 32. 

Exercise, muscular, excess of, a cause 
of acute cardiac dilatation, 496; ortho- 
static albuminuria affected by, 570; 
passive forms of, useful in hemiplegia, 
615; restriction of, in functional heart 
disease, 504; restriction of, in valvular 
heart disease, 502. 

Expectorants, objections to use of, in 
bronchopneumonia, 467; in lobar pneu- 
monia, 453 ; in measles, 340. 

Expectoration. See Sputum. 

Extremities, examination of, in illness, 
31. 

Eye, diphtheria of, 299; antitoxin in 
treatment of, 303; local treatment of, 
304. 

Eyes, care of, in measles, 340; in new- 
born, 3 ; in variola, 348. 

Eye strain, associated with epilepsy, 
692; as cause of headache, 709. 



F 



Face and head, examination of, in ill- 
ness, 29. 

Facial expression, in cretinism, 553; in 
idiocy, 623, 624; significance of, in ill- 
ness, 29. 

Facial paralysis, 98. 

Family history, bearing of, on illness, 
28. 

Fat, food value of, 101, 103; indigestion 
due to excess of, 185; proportion of, 
in buttermilk, 122; proportion of, in 
condensed milk, 127; proportion of, 
in colostrum, 108; proportion of, in 
Finkelstein 's albumin milk, 123; pro- 
portion of, in malted milk, 128; pro- 
portion of, in malt soups, 124; pro- 
portion of, in modified milk, 137; 
proportion of, in skimmed milk, 124; 
reduction of, advisable in diet during 
hot weather, 181; Walker-Gordon 
preparation furnishing, 137. 

Fatty degeneration of new-born, 82. 

Fedinski and Nicoll, use of antistrep- 
tococcic serum by, 330. 

Fetus, malaria in, 281; typhoid in, 269. 

Fever, exciting causes of, in infancy and 
childhood, 261 ; autoinf ection of non- 
bacterial origin, 262 ; excessive mus- 
cular activity, 263; heat stroke, 262; 
inanition, in first week of life, ST. 263; 
intestinal toxemia, 261,265; lobar pneu- 
monia, 264; mechanical irritation, 262; 



754 



INDEX 



' otitis media, 264; pyelocystitis, 264; 
reflex irritation, 262; septic infection, 
265 ; sepsis in second week of life, 263 ; 
systemic intoxication of bacterial 
origin, 261; tuberculosis, 264; typhoid 
fever, 265. 

Fevers, obscure, of infancy and child- 
hood, 263; antipyretics in treatment 
of, 266; diet in, 266; inanition a 
cause of, 87, 263; intestinal toxemia a 
cause of, 261, 265; lobar pneumonia a 
cause of 264; otitis media, a cause of, 
264; pyelocystitis a cause of, 264; 
septic infection a cause of, 265; ty- 
phoid fever a cause of, 265; tubercu- 
losis a cause of, 264. 

Fibrinous pneumonia. See Lobar pneu- 
monia. 

Filix mas. See Aspidium. 

Finkelstein's albumin milk, 123; use 
of, in artificial feeding of infants, 
123; in enteric infection, 194; in in- 
testinal indigestion, 201. 

FlNKELSTEIN AND MEYER, On US6 of 

casein in intestinal indigestion, 102. 

Fish tapeworm, 528, 529. 

Fischer, Martin H., on formula for rec- 
tal injections in acute nephritis, 579; 
on mineral salts in treatment of 
paroxysmal hemoglobinuria, 565; on 
rectal injections in eclampsia, 684; on 
subcutaneous alkaline injections in 
uremia, 580; on value of water in in- 
fant feeding, 106. 

Fissure of anus, 235. 

Flexner, on Shiga bacillus, 178. 

Flexner and Lewis, on inoculation of 
monkeys with poliomyelitis, 641. 

Flexner serum, action of, 637; dose of, 
636; results of, in meningococcus men- 
ingitis, 635, 637; results of, in puru- 
lent meningitis, 640; technique of ad- 
ministration, 636. 

Flies, in transmission of acute anterior 
poliomyelitis, 642; in transmission of 
typhoid fever, 268. 

Fluoroscopic examination- in pleurisy, 
476. 

Follicles at base of tongue, enlarge- 
ment of, in status lymphaticus, 547. 

Fomentations, hot, in multiple neuritis, 
663; in acute nephritis, 579; in 
pleurisy, 479. 

Fontanelles, closure of, 18. 

Food, carbohydrates in, 103; fat in, 
100; mineral salts in, 104; percent- 
ages, 139; poisoning from, a cause 
of intestinal disorders, 176; proteins 



in, 101; relation of, to weight, 14; 
water in, 105. 

Food idiosyncrasies, a cause of eczema, 
719, 722; a cause of urticaria, 726. 

"Food injuries," intestinal indigestion 
from, 184, 185; in recurrent vomiting, 
252. 

Foods, additional, in infancy and early 
childhood, 142, 143; percentage value 
of, 139; proprietary, 127; value of 
different artificial, 118. 

' ' Foot-drop/ ' 662. 

Forchheimer, on accentuation of sec- 
ond sound in diagnosis of heart dis- 
ease, 508; on adenitis in scarlet fever, 
331; on alkali treatment of rheuma- 
tism decreasing risk of endocarditis, 
492; on acute cardiac dilatation due 
to coughing spells in influenza, 496; 
on chlorate of potash in treatment of 
stomatitis ulcerosa, 151; on enanthem 
of rubella, 342; on enlargement of 
muciparous follicles in stomatitis 
catarrhalis, 147; on use of flexible col- 
lodion in adenitis, 544; on fungi pres- 
ent in stomatitis mycosa, 148; on heat 
as cause of gastroenteric intoxication, 
180; on heatstroke as a cause of fever 
in infancy, 262; on heredity in eti- 
ology of appendicitis, 223; on high 
enemata in typhoid fever for relief of 
meteorism, 278; prescription by, for 
stimulating remedy, 196; on splanchnic 
paralysis following diphtheria, 307; on 
therapeutics of chlorosis, 528; on 
transient systolic murmur in myocar- 
ditis, 507. 

Foreign bodies in larynx, trachea, 
and bronchi, 435; prognosis in, 437; 
use of X-ray in, 436. 

Formalin vapor in treatment of whoop- 
ing-cough, 293. 

Formaldehyde, as disinfectant after 
contagious diseases, 328, 339; method 
of generating, 328. 

Fowler's solution of arsenic, use of, 
after removal of neoplasms from 
larynx, 435; in malaria, 286; in pur- 
pura, 536; in chronic tuberculosis, 400. 

Frankel 's diplococcus pneumoniae, 
442. 

Freeman on temperature of pasteurized 
milk, 120. 

Freeman pasteurizer, 121. 

Freidreich's disease. See Hereditary 
ataxia. 

Fresh air, necessity of, in infancy and 
childhood, 134; necessity of, to new- 



INDEX 



755 



born, 4; therapeutic value of, 43; in 
acetonuria, 567; in bronchopneumonia, 
464, 465; in lobar pneumonia, 450; 
in acute nephritis, 581; in pleurisy, 
478; in pseudoleukemia, 526; in pur- 
pura, 535; in rickets, 244; in status 
lymphaticus, 550; in tuberculosis, 401. 

Friedlander, A., experiments by, on ef- 
fect of X-ray treatment on thymus 
gland, 549; on lymphocytosis in tuber- 
culosis of lymph-nodes, 383; on uro- 
tropin in treatment of mumps, 360. 

Fright, a cause of chorea, 698. 

Frontal sinuses, brain abscess from 
septic infection of, 618; infection of, 
in influenza, 312; purulent infection 
of, in diphtheria, 300. 

Furunculosis, 728 ; microorganisms 
present in, 728; prognosis of, 729; 
symptomatology of, 728; treatment of, 
729; in typhoid fever, 271, 274; vac- 
cine therapy for, 58, 729. 



G 



Gas bacillus. See Bacillus Welchii. 

Gastric indigestion, acute, 158; etiol- 
ogy of, 158; improper food a cause 
of, 159; physiological gastric incom- 
petency, 158; prognosis, 159; symp- 
tomatology, 159; treatment, 160. 

Gastric catarrh. See Chronic gastritis. 

Gastritis, acute, 160; corrosive form 
of, 161, 163; etiology of, 160; non- 
corrosive form of, 160, 162; pathology 
of, 160; symptomatology of, 162; tem- 
perature changes in, 161; treatment 
of, 162. 

Gastritis, chronic, 170; diagnosis of, 
171; diet in, 172; etiology of, 170; 
hygiene in, 173; pathology of, 171; 
prognosis of, 172; stomach washing 
in, 172; symptomatology of, 171; 
treatment of, 172. 

Gastroenteritis, after bronchopneu- 
monia, 462; in influenza, 310, 314. 

Gastroduodenitis, 165. 

Gastrointestinal disorders, albumin 
water of value in, 128; bronchopneu- 
monia associated with, in new-born, 
461; buttermilk of value in, 123; 
chorea caused by, 697; drugs in causa- 
tion of, 39; eczema due to, 719; epi- 
lepsy associated with, 695 ; Finkel- 
stein 's albumin milk of value in, 123 ; 
frequency of, in congenital heart dis- 
ease, 489; fresh air of value in, 44; 
headache due to, 709; indicanuria 



present in, 562; insomnia associated 
with, 676, 677; meat preparations of 
value in, 129; mortality from, in in- 
fancy, 2; Nestle 's food of value in, 
127; pavor nocturnus associated with, 
671; premature infants susceptible to, 
64; rickets associated with, 240; 
skimmed milk of value in, 124; urti- 
caria due to, 726; water of value in, 
47, 128. 
Gaucher, on primary splenomegaly, 552. 
Gavage, indications for, 50. 
Gay and Lucas, on blood changes in 

acute anterior poliomyelitis, 649. 
Gelatin, subcutaneous injection of, in 
hemophilia, 539; in hemorrhage of 
new-born, 83. 
Geographical tongue, 155. 
Gerhardt, on physical signs in persist- 
ent patulous ductus arteriosus, 488. 
German measles. See 'Rubella. 
Gibson, on diagnostic value of discharge 
of bloody mucus in intestinal intus- 
susception, 220. 
Gigantoblasts, 515. 
Glossitis, desquamative. See Geo- 
graphical tongue. 
Glycerin ointment, use of, in acute 
catarrhal bronchitis, 441; in mumps, 
360. 
Goldberg and Anderson, on production 

of measles in monkeys, 332. 
Gonococcus of Neisser, in cystopyelitis, 
584; in vulvovaginitis, 591, 592, 595. 
Gonococcus vaccine, therapeutic use of, 

58. 
Gout, a cause of asthma, 711 ; of eczema, 

722; of headache, 708. 
Grand mal, 692. 

Griffith, Crozer, on diagnosis between 

appendicitis and lobar pneumonia, 449 ; 

on incubation period of rubella, 341; 

on prognosis in typhoid fever, 275. 

Grozy, experiments by, on dextrimaltose 

preparations, 125. 
Gruber-Widal reaction, in paratyphoid 
fever, 275; in typhoid fever, 265, 269, 
273; in diagnosis between typhoid 
fever and tuberculous peritonitis, 391. 
Grunbaum, on typhoid fever in the chim- 
panzee, 267. 
Guaiacol, therapeutic use of, in acute 
catarrhal bronchitis, 441 ; in convales- 
cence from bronchopneumonia, 469; in 
cystopyelitis, 587; in measles, 340; in 
pseudoleukemia, 526; in tuberculous 
peritonitis, 401; in typhoid fever, 277; 
in urticaria, 728. 



756 



INDEX 



Guaiacol, inhalations of, in acute laryn- 
gitis, 433; in acute rhinitis, 414. 

Guaiacol ointment, use of, in adenitis, 
544; in acute catarrhal bronchitis, 442; 
in bronchopneumonia, 469 ; in cysto- 
pyelitis, 587; in measles, 340; in 
mumps, 360; in tuberculosis, 398; in 
tuberculous bronchopneumonia, 401 ; 
in tuberculous peritonitis, 401. 

Guanier, description by, of microorgan- 
isms in variola, 345. 

Gummatous ulceration, in late heredi- 
tary syphilis, 367. 

Gymnastic exercises, therapeutic value 
of, 53; value of, in rachitis, 245. 

< ' Gyrospasm, " 689. 



Habit, a cause of enuresis, 600; a cause 
of pseudomasturbation, 606. 

Habit spasm, 701; definition of, 701; 
etiology of, 702; prognosis of, 702; 
symptomatology of, 702; treatment of, 
703. 

Hadden, W. B., on head-nodding in 
child, 689, 690. 

Hall, on value of pressure signs in lymph 
node tuberculosis, 385. 

Hamburger, description of skin tuber- 
culides, by, 384. 

Hamill, on late systolic pulmonary mur- 
mur, 507; on percussion, 32, 33. 

Hamilton, Alice, on susceptibility of 
vulvovaginal canal in young children 
to gonorrheal infection during scarlet 
fever, 591; on vaccine therapy in 
treatment of gonorrheal vaginitis, 594. 

Hardaway and Grindon, prescription 
by, for ointment for use in eczema, 
724; for ointment for use in tinea ton- 
surans, 734; for lotion for use in urti- 
caria, 727; on Crocker's method of 
treatment in tinea tonsurans, 735. 

Harelip, 156. 

Hastings, measurements by, of growth 
in children, collected by, 17. 

Head and neck, examination of, in ill- 
ness, 30. 

Head, measurements of, in childhood, 18 ; 
nodding, 689; palpation of, 30; posi- 
tion of, in illness, significant, 29. 

Headache, 708; anemic form of, 708; 
due to brain tumor, 616; etiology of, 
708; in meningococcic meningitis, 632; 
organic form of, 709; reflex form of, 
709; remedies for relief of, 710; toxic 
forms of, 709 ; treatment of, 709 ; due 
to uremia, 576. 



Hearing, sense of, in infants, 22. 

Heart, acceleration of action in infancy, 
483; displacement of, in pleurisy, with 
effusion, 473, 476; disturbance of, in 
acute articular rheumatism, 404; dis- 
turbance of, in chorea, 700; enlarge- 
ment of, in congenital heart disease, 
486. 

Heart, disease of, associated with acute 
articular rheumatism, 404; displace- 
ment of, in pleurisy with effusion, 473, 
476; disturbance of, in chorea, 700; 
enlargement of, in stenosis of pul- 
monary artery, 487; growth of, in 
infancy and childhood, 484; hyper- 
trophy of, in persistent patulous duc- 
tus arteriosus, 488; murmurs, see Mur- 
mur; peculiarities of, in childhood, 
483; rest, in treatment of disease of, 
504. 

Heart, acute dilatation of, 496; diag- 
nosis of, 496; diagnosis of, from peri- 
carditis, 511; etiology of, 496; prog- 
nosis of, 496; prophylaxis of, 497; 
treatment of, 498. 

Heart disease, congenital, 484; blood 
changes in, 486; differential diagnosis 
between different forms of, 486; eti- 
ology of, 484; malformations a cause 
of, 485; special lesions in, 486; symp- 
tomatology of, 485; treatment of, 488. 

Heart disease, functional, 506; ar- 
rhythmia, as form of, 506; brady- 
cardia, as form of, 507; diet in, 508; 
etiology of, 506; frequency of, in 
child, 506; murmurs associated with, 
507, 508; paroxysmal tachycardia, as 
form of, 506; treatment of, 508. 

Heart, chronic valvular disease of, 
498; acute articular rheumatism, a 
cause of, 498; aortic regurgitation a 
form of, 501; aortic stenosis a form 
of, 501; compensation in, 502; diet in 
treatment of, 504; drugs in treatment 
of, 504; endocarditis in causation of, 
498; etiology of, 498; exercise in 
treatment of, 504; failure of compen- 
sation in, 502; hygiene in treatment 
of, 504; mitral regurgitation of, 499; 
mitral stenosis a form of, 500; prog- 
nosis in, 502 ; treatment of, 503 ; treat- 
ment of failing compensation in, 505; 
tricuspid regurgitation, 502. 

Heat-dissipating mechanism, increasing 
stability of, 27; relative importance 
of, in child, 26. 

Heat, inhibitory centers. See Thermo- 
inhibitory centers. 



INDEX 



757 



Heat-psoducing centers. See Thermo- 
genic centers. 

Heat-regizlating MECHANISM, develop- 
ment of, 25; peculiarities of, in pre- 
mature infant, 62. 

Heat stroke, 262. 

Hebea's formula, 725. 

Heidtngsfeld, formula for lotion by, 
724; formula for ointment by. 735; 
on treatment of pediculosis capillitii, 
737. 

Height, at different ages, 17. 

Heimanx, on demonstration of gonoeoe- 
cus in gonorrheal vaginitis. 592. 

Hektoen. on relation of streptoeoe- 
eemia to severity of scarlet fever, 317. 

Hematoma of sternoclfjdoma b i ; : d 
muscle ix new-bosh, r s 

Hematuria, 562; in acute nephritis. 577: 
in tumor of the kidney. 588; treat- 
ment of, 563. 

Hemiplegia, 612; treatment of, 615. 

Hemoglobin*, variations of, in blood of 
infants, 519; in chlorosis 526; in 
Hodgkin's disease, 541: in pernicious 
anemia. 529; in pseudoleukemia. 525; 
in simple secondary anemia.. "_: in 
status lymphati.v- 547 

Hemoglobesuria, 563; diagnosis be- 
tween, and hematuria. 564: epidemic 
form of, in new-born, 82, 564; etiology 
of, 563; paroxysmal, 564: due to 
poisons, 564; prognosis :z. 565; treat- 
ment of, 565: Tyres :r. 71- 

Hemophilia, 537: definition of. 537; 
diagnosis of, 539; drugs in treatment 
of. 539: etiology of. 537; prophylaxis 
of. 539: serum treatment of. 540; 
svmptomatologv of. 538; treatment of, 
539. 

Hemorrhage, cerebral, a cause of men- 
tal deficiency. 623: from conjunctiva 
in whooping-cough. 2S9: meninges.", a 
cause of infantile palsy. 610: from 
mucous membranes in purpura. 533; 
from the respiratory tract in whoop- 
ing-cough 28£ in aenrvy 848; in fcy- 
phoid fever, from intestines. 272. 878 

H::::j.?.e^?z ::~ z~ -e;: ?2 me - 
congenital syphilis. S3 ; doe to epidemic 
hemoglobinuria ; _. etiology of. 82; 
due to acute iitty iegeneratior B2; 
from inte;-:::e ; . 4; due to melena neo- 
natorum. S2: prognosis of. S3: due to 
septic infection. 78 fcn sfosian for 
relief of, M "r-itment of, S3; from 
umbilicus. 35 

Henoch, on duration of typhoid fever. 



269; on pneumonia cornpl: 
measles. 337: or. ',: r. . r . 

I berenlons pei 391. 

Henoch's pubpubj 534 ontra- 

indicated in, 537. 

HErcEi/.TT, .:/:.. ■-.:.■/-. :: 

425 Leitis, 

223: of acute articular rneumal 
102; of asthma, 711: .: genital 

seasc 185; of e mgenital ich- 
thyosis " of eclampsia, 679; of ec- 
ze - " :e endocarditi- 

of epilep ay 691 spasm " 

of headache. 708; of hemophilia. 7 . " 
of hereditary ataxia, 657; of hydro- 
. / : . : I ! : . f bjstens ' ! 7 I 
idiocy S23 :f insomnia, 676; of mas- 
tnrbatioi] 606; of nystagmus, 
of orthostatic albuminuria. 

er-fatigue at school, 9; of pavor 
nocturnus, 671; of progressive muscu- 
lar dystrophy, 666; of pseudomastur- 
bation. 606; of recurrent vomiting, 
252 if spots Ik 553; of 

tubereiil " " : of urtica: 

Hernia, associated with rickets, 240; 
caused by whooping-cough, 289; con- 
genita". 87 ; zmbilieal, in new-born, 86; 
umbilical, in sporadic cretinism, : r ^ 

Heroix HTBBOCHLORATE, use of, in in- 
fluenza, 314; in whooping-eough. 294 

Hester, mi indolaceturie 562 :r± re- 
sults of acid intoxication, 566. 

Hedbheb on food consumption in in- 
fant?. 131; ;n immnnitjr of young in- 
fant- fcc scarlet fever, 17: on ortho- 
stati: ilrziriit-zris 7 '. : 71'.: 

Zzz^ ::irzTiz . : ::. fee 7 r 0fropm. 

Hif-jodjt, tdbexenIosi£ if, U92 

Hi25H5?2~":; : " "■-. :■: : _ ~ - - ' : -'--■ 
genital dilatation of colon, 1 3 

HlSTOft Y-TAKING ES IUJfKS^ _: 

Hirzz. >z? ". _ : :.::-.-"". - : t.er: • 
ditis in children, 509; on physical 
Bagns in defective septum, 488; on re- 
lation between heart weight and body 
weight in ini - ~ rJlitie 

tset 1:7. aT&.ysis. :l'-7 \- X-ray tres.t 
m ent of enlarged thymus, 549. 

Hodge 7 :n changes in nerve cells 

as result of nerve 11- 

blood changes 

in, 541: definition ' 540; diagnosis 

: 541 . iDlogy 

f. 5-3 . - - - ~ _ - r 

fcology 541; tore changes 

" - - 

_ ?trostomy performed by. 



758 



INDEX 



in congenital malformation of the 
esophagus, 158. 

Hoffmann's sign, 688. 

Holding-the-breath spells, in laryn- 
gismus stridulus, 685. 

Holt, apparatus devised by, for exam- 
ining breast milk, 110; on use of 
atropin in enteric infection, 195 ; on 
use of atropin in treatment of enure- 
sis, 602; on composition of human 
milk, 110; on dilatation of stomach, 
163; on gonococcus in vulvovaginitis, 
591; on method of obtaining mucus 
for examination in tuberculosis, 389; 
on use of morphin in enteric infection, 
195; on mortality in measles, 338; on 
primary cases of nephritis, 575; on 
quantity of milk required by normal 
infant, 110 ; report by, on gonorrheal 
arthritis, 593; on salicylate of soda to 
control gastric fermentation, 173 ; on 
skimmed milk in diet of infants, 126; 
on transmission of cancrum oris, 152. 

Holt's inanition fever, 87, 263; diag- 
nosis of, 88; etiology of, 88; obscure 
rise of temperature due to, 263; 
symptomatology of, 88; treatment of, 
89. 

Holt and Bartlett, on acute anterior 
poliomyelitis, 642, 650. 

Holt and Northrup, on primary in- 
testinal tuberculosis, 380. 

Hookworm, presence of, in pernicious 
anemia, 528, 529. 

Howlands and Eichards, on recurrent 
vomiting, 251, 254. 

Huber, analysis by, of cases of menin- 
gococcic meningitis, 632; of blood ex- 
amination in meningococcic meningitis, 
634. 

Human milk. See MilTc. 

Hutchinson, Jonathan, formula by, for 
use in tinea tonsurans, 734; on late 
hereditary syphilis, 366. 

Hutchinson's teeth, 146. 

Hyacin hydrobromate, in chorea, 701. 

Hydrencephalocele, 622. 

Hydriodic acid, syrup of. See Syrup. 

Hydrocele, 597. 

Hydrocephalus, acute, 618. 

Hydrocephalus, chronic internal, 
618.; definition of, 618; etiology of, 
619 ; imbecility associated with, 623 ; 
mortality from, 620; pathology of, 
619 ; prognosis of, 620 ; symptoma- 
tology of, 619 ; treatment of, 620. 

Hydrochloric acid, therapeutic use of, 
in typhoid fever, 277. 



Hydronephrosis, 589. 

Hydrotherapy, 44; use of, in hysteria, 
708; in lobar pneumonia, 451; in acute 
nephritis, 579; in purpura, 536; in 
chronic rheumatic arthritis, 409 ; in 
scarlet fever, 329 ; in typhoid fever, 
277; value of, as means of treatment, 
44. 

Hygiene, general, principles of, in in- 
fancy and childhood, 2. 

Hygienic treatment, of bronchopneu- 
monia, 465; of enteric infection, 197; 
of chronic intestinal indigestion in 
infants, 201; of lobar pneumonia, 450; 
of recurrent vomiting, 257. 

Hymenolepis nana, 212. 

Hypertrophy of heart, in persistent 
patulous ductus arteriosis, 488; in 
chronic valvular heart disease, 499. 

Hypertrophy of the pyloris, congeni- 
tal. See Congenital. 

Hypodermoclysis, 48; use of, in diph- 
theria, 307; method of using, 48; use 
of, in nephritis, 580; use of, in scarlet 
fever, 330; therapeutic value of, 48; 
use of, in typhoid fever, 278. 

Hypospadias, 597. 

Hysteria, 706; treatment of, 707. 



Ice, therapeutic use of, 47. 

Ice-bag, therapeutic use of, in adenitis 
of scarlet fever, 331; in acute cardiac 
dilatation, 498; in cystopyelitis, 587; 
in diphtheria, 304; in acute endocardi- 
tis, 493; in fevers, 266; in headache, 
701; in heart complications of acute 
rheumatism, 406; in Henoch's pur- 
pura, 537; in intestinal hemorrhage, 
278; in malaria, 286; in mastoiditis, 
718; in meningococcic meningitis, 
638; in acute pericarditis, 512; in 
pleurisy, 478; in purpura hemor- 
rhagica, 537; in tonsillitis, 423; in ty- 
phoid fever, in connection with baths, 
277, 278; in variola, 348. 

Ice-cap, therapeutic value of, 46; in 
eclampsia, 682; in lobar pneumonia, 
451. 

Ice-cream, a source of infection in ty- 
phoid fever, 268. 

Ichthyol ointment, therapeutic use of, 
in erysipelas of new-born, 81; in 
scarlet fever, 330. 

Ichthyosis, congenital. See Congenital. 

Icterus neonatorum, 92; symptoma- 
tology of, 93; treatment of, 93. 

Icterus, other forms of, in new-born, 94. 



INDEX 



759 



Icterus, in toxic nephritis, 572; in 
Winckel's disease, 564. 

Idiocy, 622; acquired, 623; amaurotic 
family, 624; congenital, 622; defini- 
tion of, 622; due to epilepsy, 694; 
etiology of, 622; microcephalic, 625, 
626; Mongolian, 554, 625; prognosis 
of, 624; sporadic cretinism, 554; 
symptomatology of, 623; treatment 
of, 624. 

Iglauer, on avoidance of general anes- 
thesia in evacuation of retropharyn- 
geal abscess, 429. 

Imbecility, associated with epilepsy, 
694; with infantile cerebral palsies, 
613, 614. 

Impetigo contagiosa, 731; treatment of, 
732. 

Inanition fever, Holt's. See Holt. 

Incontinence of urine, occurrence of, 
in eclampsia, 681; in hypospadias, 
598; in myelitis, 654, 656; in night- 
terror, 673; physiologically in infancy, 
561. 

Incubator, 66. 

Indican, absence . of, in urine of new- 
born, 562; derivation of, in urine, 562. 

Indicanuria, 562; in headache, 709; in 
chronic intestinal indigestion, 202; in 
intestinal toxemia, 265; in orthostatic 
albuminuria, 569; a sign of putre- 
factive changes in intestine, 205. 

Indolaceturia, cause of, 562; presence 
of, in intestinal toxemia, 205; pres- 
ence of, associated with putrefactive 
changes of intestine, 205. 

Infancy, chief causes of death in, 1; 
clothing in, 5; contagion in, 6; fresh 
air in, 4; head-measurements in, 18; 
heat-regulating mechanism in, 25; 
height in, 17; hygiene during, 2, 10; 
malaria in, 283; muscular develop- 
ment in, 20; nervous activity in, 6; 
nervous system in, 23; nursery in, 5; 
peculiarities of blood in, 518; rest in, 
4; sleep in, 4, 671; special senses in, 
22; spinal development in, 22; suscepti- 
bility to high temperatures in, 27,260; 
therapeutics of, 38; weight in, 13, 15. 

Infantile atrophy, 199. 

Infantile cerebral palsies, 610; defi- 
nition of, 610; diagnosis of, 615; diet 
in, 615; etiology of, 610; orthopedic 
treatment of, 616; pathology of, 611; 
prognosis of, 615; symptomatology of, 
612; treatment of, 615. 

Infantile myxedema. See Cretinism, 
sporadic. 



Infantile spinal paralysis. See Acute 
anterior poliomyelitis. 

Infantile scurvy, 246; blood changes 
in, 248; curative treatment of, 249; 
definition of, 246; diagnosis of, 248; 
diet of, 249; etiology of, 246; morbid 
anatomy in, 247; prognosis of, 249; 
prophylactic treatment of, 249 ; rheu- 
matism mistaken for, 404; symptoma- 
tology of, 247; temperature changes 
in, 248; toxic nephritis associated 
with, 572; treatment of, 249; urine 
findings in, 248. 

Infection, sources of, in adenitis, 377; 
in adenoid disease, 425; in appendi- 
citis, 223 ; in acute catarrhal bronchi- 
tis, 438; in diphtheria, 295; in acute 
endocarditis, 490; in enteric infection, 
189; in erythema infectiosum, 343; in 
gonorrheal vulvovaginitis, 591; in 
impetigo contagiosa, 731; in influenza, 
308; in acute intestinal toxemia, 176; 
in lobar pneumonia, 433; in malaria, 
280; in mastoiditis, 717; in measles, 
332; in meningococcic meningitis, 
631; in mumps, 357; in mycotic ne- 
phritis, 574; in myelitis, 652; in myo- 
carditis, 494; in acute nephritis, 572; 
in chronic nephritis, 584; in ophthal- 
mia neonatorum, 94; in otitis media, 
714; in pericarditis, 509; in peritoni- 
tis, 228, 229; in acute anterior polio- 
myelitis, 642; in retropharyngeal ab- 
scess, 427; in acute rhinitis, 411; in 
rubella, 341; in scarlet fever, 316; in 
sepsis of new-born, 75 ; in sinuses, 
frontal and ethmoid, from diphtheria, 
300; in syphilis, 361; in tetanus 
neonatorum, 89 ; in tonsillitis, 419 ; in 
tuberculosis, 373; in tuberculous 
meningitis, 627; in typhoid fever, 
268; in simple vaginitis, 595; in 
variola, 345. 

Infection, susceptibility to, in prema- 
ture infant, 64. 

Infectious diseases, acute, chorea fol- 
lowing, 697; congenital heart disease 
due to, in mother, 485 ; cystopyelitis 
due to, 584; danger from, in status 
lymphaticus, 550; eclampsia due to, 
680; endocarditis due to, 490; enure- 
sis due to, 599 ; milk of nursing 
mother affected by, 112; acute ne- 
phritis due to, 578; mycotic nephritis 
due to, 574, 575; predisposing cause 
in gonorrheal infection of vagina, 
595; predisposing cause in transmis- 
sion of tuberculosis, 375; purpura due 



760 



INDEX 



to, 532; splenic enlargement asso- 
ciated with, 552; danger from, in 
status lymphaticus, 550; urine ex- 
amination in, 559. 

Influenza, 308; after-treatment of, 315; 
bacillus of, 308, 311; acute cardiac 
dilatation due to, 496; characteristics 
of, in infancy, 311; chronic form of, 
311; climatic influences in, 308; 
climatic treatment of, 310, 314; com- 
plications in, 311; coryza in, 310; defi- 
nition of, 308; danger from, in in- 
fancy, 5; danger from, to tuberculous 
children, 595; definition of, 308; diet 
in, 313; drugs in, 313; etiology of, 
308; eruptions in, resembling scarlet 
fever, 325; gastroenteritis in, 310, 
311; immunity from, 311; incubation 
period in, 309; local treatment of, 314; 
mortality from, in infancy, 2; multi- 
ple neuritis from, 661; nephritis due 
to, 312; nervous symptoms in, 308; 
pathology of, 309; prognosis of, 312; 
prophylaxis of, 312; nervous symptoms 
in, 308 ; pathology of, 309 ; prognosis 
of, 312; prophylaxis of, 312; skin erup- 
tions in, 310, 311; sources of infection 
in, 308; symptomatology of, 309; 
symptom groups in, 310; temperature 
curve in, 309, 311; treatment of, 313; 
eruptions in, 310, 311; sources of in- 
fection in, 308 ; symptomatology of, 
309; symptom groups in, 310; tem- 
perature curve in, 309, 311; treatment 
of, 313. 

Inhalations, in treatment of acute 
laryngitis, 433; of laryngeal diph- 
theria, 304; of acute rhinitis, 433. 

Inhibitory function, development of, 
24. 

Injections, hypodermic, of adrenalin, 
307; of caff em, 307, 330; of camphor, 
307; of ether, 307; of salt solution, 
580; therapeutic value of; see Hypo- 
dermoclysis. 

Injections, intravenous, in acute ne- 
phritis, 579. 

Injections, nasal, in epistaxis, of 
adrenalin, 416; in acute rhinitis, 414. 

Injections, rectal, of Fischer 's alkaline 
solution in acute nephritis, 579, 580; 
of food in artificial feeding, 52; of 
olive oil in constipation, 51 ; of salt 
water in constipation, 51, 207; of salt 
water in flushing the colon, 51; thera- 
peutic value of, 51. 

Injections, vaginal, in gonorrheal 
vulvovaginitis, 594. 



Inoculation, anti-typhoid, 276. 

Inorganic constituents of milk, 104; 
necessity o*f, to nutrition, 105. 

Insolation. See Heat-stroke. 

Inspection, examination by, in sick- 
ness, 29; of face, 29; of general posi- 
tion, 30; of head, 29; of respiration, 
30; of skin, 30. 

Intestinal colic, 184. 

Intestinal discharges, examination of, 
in illness, 34; danger in handling, 179; 
nature of, in intussusception, 220. 

Intestinal disorders of infancy, 173; 
age a predisposing cause, 179; bad 
hygiene a predisposing cause, 180; 
bacteria present in, 176, 177, ,178, 179; 
bathing in prophylaxis of, 182; change 
of climate in treatment of, 181; cloth- 
ing in prevention of, 183; dentition as 
a cause of, 176; etiology of, 173; ex- 
posure to cold and wet a cause of, 
176; over-feeding a cause of, 175; 
predisposing factors in, 174; prophy- 
laxis of, 180; summer heat a predis- 
posing factor in, 179; swallowing 
mucus a cause of, 176. 

Intestinal fermentation, 103. 

Intestinal indigestion, acute, diagno- 
sis of, 187; diarrhea in, 183; fat indi- 
gestion in, 185; food injuries in, 184, 
185; nervous symptoms in, 184; pain 
in, 184; pathology of, 183; prognosis 
of, 187; protein indigestion in, 186; 
sugar indigestion in, 186; symptoma- 
tology of, 183 ; symptom group in, 
184; temperature curve in, 184; treat- 
ment of, 187. 

Intestinal indigestion in infants, 
chronic, 197; diet in, 200; etiology 
of, 197; hygienic treatment of, 201; 
infantile atrophy from, 199 ; marasmus 
in, 200; medicinal treatment of, 201; 
pathology of, 198; symptomatology of, 
198; treatment of, 200. 

Intestinal indigestion in older chil- 
dren, chronic, 201; climate in treat- 
ment of, 203; diet in, 203; etiology of, 
201; medicinal treatment of, 203; 
prognosis of, 203; symptomatology of, 
202; treatment of, 203. 

Intestinal intoxication. See Intes- 
tinal toxemia. 

Intestinal obstruction, acute, in ap- 
pendicitis, 224. 

Intestinal parasites. See Parasites. 

Intestinal perforation, in typhoid 
fever, 272, 279. 

Intestinal toxemia, 176; a cause of 



INDEX 



761 



asthma, 711; of eclampsia, 680; of 
fever, 261; of headache, 709. 

Intestinal tuberculosis, 380. 

Intubation, in acute laryngitis, 433; in 
edema of the larynx, 434; in laryn- 
geal diphtheria, 304, 305; method of 
performing, 305. 

Intussusception of the intestines, 
219; course of, 221; definition of, 219; 
diagnosis of, 222; etiology of, 219; 
intestinal discharges in, 220; pathol- 
ogy in, 220; physical signs of, 221; 
prognosis of, 221; symptomatology of, 
220; temperature curve in, 221; treat- 
ment of, 221; vomiting in, 220. 

Inunctions of guaiacol, therapeutic 
use of, in adenitis, 544; in broncho- 
pneumonia, 469; in acute catarrhal 
bronchitis, 442; in lobar pneumonia, 
452 ; in measles, 340 ; in pleurisy, 479 ; 
in tuberculous bronchitis, 401. 

Inunctions, drugs suitable for use by, 
42, 43; method of giving, 42; of oil 
in rickets, 245; in scarlet fever, 330; 
therapeutic value of, 41. 

"Inward spasm." See Laryngismus 
stridulus. 

Iodid of potash. See Potassium iodid. 

Iodid of iron, syrup of. See Syrup. 

Iodin, use of, by inunction, 42, 43; in 
chronic pericarditis, 513; in pleurisy, 
479; in tuberculosis of lymph-nodes, 
399. 

Iodin, therapeutic use of internally, in 
adenitis, 544; in sporadic cretinism, 
556; in syphilis, 371; in tuberculosis, 
399. 

Iodid of potassium. See Potassium 
iodid. 

Ipecac, syrup of. See Syrup. 

Iron, importance of, to nutrition, 104; 
tincture of chlorid of, 81. 

Iron, syrup of iodid of. See Syrup. 

Iron, therapeutic use of, in adenitis, 544 ; 
in asthma, 713; in acute cardiac dila- 
tation, 498; in chlorosis, 527, 528; 
in chorea, 701; in convalescence from 
influenza, 315; in convalescence from 
acute laryngitis, 433 ; in convalescence 
from lobar pneumonia, 451; in enure- 
sis, 601; in facial paralysis, 666; in 
hemophilia, 539 ; in multiple neuritis, 
664; in nystagmus and head-nodding, 
691; in pavor nocturnus, 675; in pre- 
vention of laryngismus stridulus, 686; 
in pseudoleukemia, 526; in pseudo- 
masturbation, 609 ; in purpura, 536, 
537; in rickets, 245; in simple anemia, 



524; in status lymphaticus, 580; in 
tonsillitis, 423 ; in tetany, 689 ; in 
valvular heart disease, 505. 

Irrigation, of bladder in cystopyelitis, 
587; of colon in enteric infection, 51, 
193, 195; of vagina in gonorrheal vul- 
vovaginitis, 594; of stomach; see Ga- 
vage. 

Insomnia, 675; etiology of, 676; prophy- 
laxis of, 677; treatment of, 617; 
varieties of, 676. 

Isolation, in influenza, 312; in measles, 
338; in mumps, 360; in scarlet fever, 
327; in tonsillitis, 422; in typhoid 
fever, 276; in variola, 348. 

Itch. See Scabies. 



Jacksonian epilepsy, 693. 

Jacobi, on use of belladonna in whoop- 
ing cough, 293 ; on use of cereals in 
artificial feeding, 126; on diet in 
fevers, 266; on lymphoid ring of 
pharynx as portal of infection, 490; 
on mitral stenosis without a heart 
murmur, 500; on peroxid of hydrogen* 
as an irritant to the throat, 423 ; on 
rickets as cause of laryngismus stridu- 
lus, 684; on relative length of colon 
in infectious disease, 204; on strap- 
ping chest for relief of pain in pleu- 
risy, 478; on tonsillitis, as opening for 
infection, 478; on uric acid in infants, 
561. 

James, apparatus devised by, for breath- 
ing exercises after operation for em- 
pyema, 481. 

Jaundice, catarrhal form of; see Gas- 
troduodenitis; of new-born; see Icte- 
rus neonatorum ; in septic infection of 
new-born, 77. 

Jenner, Edward, discovery of vaccina- 
tion by, 349. 

Jehle, on lordosis of lumbar vertebrae, 
as cause of orthostatic albuminuria, 
569. 

Johnson, W. W., on mortality from 
whooping-cough, 291. 

Joints, tuberculosis of, 381, 391; 
treatment of, 401. 

Joint contraction in hysteria, 706. 

K 

Kassowitz and Jacobi, on phosphorus 

in treatment of rickets, 245. 
Keller, on injury to metabolic processes 



762 



INDEX 



from over-feeding, 175; on intestinal 
disorders following over-feeding, 174, 
175; introduction by, of malt soups 
as artificial food for infants, 124; on 
symptom group in acute intestinal in- 
digestion, 184. 

Keratitis, syphilitic interstitial, 367. 

Kerley, on care of milk in tenements, 
182; on composition of human milk, 
108; on gavage, 50; on method for 
preventing pseudomasturbation, 182; 
on rectal enemata of olive oil in con- 
stipation, 51, 207. 

Kernig's sign, significance of, in sick 
child, 32; significance of, in menin- 
gococcic meningitis, 633 ; in acute an- 
terior poliomyelitis, 645; in purulent 
meningitis, 633, 635; in tuberculous 
meningitis, 628. 

Kidney, cystic degeneration of, 589; dis- 
location of, 590 ; enlargement of, in 
syphilis, 359, 366; size of, at birth, 
590; tuberculosis of, 590. 

Kidney tumors, 587; etiology of, 587; 
mortality from, 589; nature of, 587; 
operative treatment for, 589 ; symp- 
tomatology of, 588; treatment of, 589. 

Kilmer, on use of abdominal belt in 
whooping cough, 293. 

Kirmisson, operation by, for obstruc- 
tion of esophagus, 158. 

Kjelberg, on gastrointestinal disease, as 
cause of toxic nephritis in infancy, 
572. 

Klebs-Loffler bacillus, description of, 
295; in diagnosis between diphtheria 
and tonsillitis, 420; in etiology of 
diphtheria, 295; in stomatitis gan- 
grenosa, 153. 

Klein and Gordon, description by, of 
streptococcus scarlatina, 317. 

Knee-joint tuberculosis, 393. 

Koch's bacillus, 273. 

Koch's tuberculin, therapeutic use of, 
58. 

Kolmer and Weston, on vaccine 
therapy in sequelae of scarlet fever, 
332. 

Konig, on results of removal of thymus 
gland, 551. 

Koplik, on diagnosis of hypertrophy of 
pylorus, 167, 168; on diagnosis of 
pyloric spasm, 168 ; on enanthem 
stage of measles, 334; on frequency 
of simple vulvovaginitis in children, 
595 ; on gonococcus peritonitis, 230 ; 
on gastrointestinal disease as cause of 
toxic nephritis, 572; on inflammation 



of cervix uteri in gonococcus vulvo- 
vaginitis, 592; on presence of pneu- 
mococcus in pleurisy in children, 470; 
on presence of streptococcus in retro- 
pharyngeal abscess, 248; tables by, on 
physical measurements of average boys 
and girls, 17, 18; on temperature of 
milk in infant feeding, 120. 

Kurth, description by, of streptococcus 
conglomeratus, 317. 

KiiSTNER, Otto, on rudimentary condi- 
tion of genitourinary organs in little 
girls, 604. 

Koplik spots, 335. 



Ladd and Wetter, on influence of anti- 
meningitic serum on joint affection, 
635. 

La Fetra, on eosinophilia in asthma. 

Landouzy-Dejerine type of progress- 
ive MUSCULAR DYSTROPHY, 668. 

Landry's paralysis, 645. 

Landsteiner and Popper, on inocula- 
tion of monkeys with acute anterior 
poliomyelitis, 641. 

Langstein, on symptom group in acute 
intestinal indigestion, 184. 

Lanolin, therapeutic use of, by inunc- 
tion, 43; in measles, 339; in acute 
rhinitis, 415; in rickets, 245; in scar- 
let fever, 330; in varicella, 359. 

Laryngeal stridor, 437; treatment of, 
438. 

Laryngismus stridulus, 684; defini- 
tion of, 684; diet in, 686; etiology 
of, 684; prevention of attack, 685; 
prognosis of, 685; symptomatology of, 
685; treatment of attack, 685; treat- 
ment of underlying condition, 686. 

Laryngitis, acute, 429; definition of, 
429; diagnosis of, 431; drugs in 
treatment of, 432; dyspnea in, 431; 
etiology of, 429; microorganisms pres- 
ent in, 429; pathology of, 430; prog- 
nosis of, 432; sources of infection in, 
429; spasmodic form of, 430; symp- 
tomatology of, 430; temperature curve 
in, 431; treatment of, during attack, 
432; treatment of, during interval, 
433. 

Laryngitis, catarrhal form of, in 
measles, 337; membranous form of, 
in measles, 337, 340; syphilitic form 
of, in new-born, 364. 

Laryngospasm. See Laryngismus strid- 
ulus. 



INDEX 



763 



Larynx, diseases of, 429; congenital 
laryngeal stridor, 437; edema of the 
larynx, 434; foreign bodies in, 435; 
acute laryngitis, 429; neoplasms in, 
435. 

Lavage, 49; in chronic gastritis, 172; in 
hypertrophy of the pylorus, 170. 

Laveran, discovery by, of plasmodium 
malariae, 279. 

Lead poisoning, a cause of multiple 
neuritis, 661. 

le Boutillier, on late systolic pulmo- 
nary murmur, 507. 

Ledermann, on Wassermann reaction 
in hereditary syphilis, 368. 

Leeches, therapeutic use of, in acute 
cardiac dilatation, 498; in mastoidi- 
tis, 718. 

Leukemia, 530; blood picture in, 530; 
definition of, 530; diagnosis between, 
and Hodgkin's disease, 542; diagnosis 
between, and pseudoleukemia, 525; eti- 
ology of, 530; lymphoid form of, 530; 
myeloid form of, 530; prognosis of, 
531; symptomatology of, 530; tem- 
perature changes in, 531; treatment 
of, 531. 

Leukocytes. See Blood corpuscles, 
white. 

Leukocytosis, in chlorosis, 527; in 
diagnosis of sepsis, 265; in diagnosis 
of typhoid fever, 273; in diphtheria, 
297; in infancy, 519; in influenza, 
310; in lobar pneumonia, 447; in 
measles, 336; in meningococcic menin- 
gitis, 634; in mumps, 359; in polio- 
myelitis, 649; in rubella, 343; in 
simple anemia, 523; in status lympho- 
cytosis, 547; in syphilis, 366; in 
whooping cough, 289; in varicella, 
356; in variola, 347. 

Leveran and Catrin, investigation by, 
of blood in mumps, 357. 

Ligaments, weakness of, in rickets, 240. 

Lime water, value of, in artificial feed- 
ing, 139. 

Lipase, presence of, in milk, 106. 

Lithuria, 561. 

Liver, abscess of, in lobar pneumonia, 
448; displacement of, in pleurisy with 
effusion, 476; enlargement of, in sim- 
ple anemia, 523; enlargement of, in 
pseudoleukemia, 531; functional dis- 
turbance of, in purpura, 532; incom- 
petency of, a cause of recurrent vomit- 
ing, 251. 

Loffler, on blood serum, 295; on chil- 



dren as carriers of malarial parasites, 
281. 

Longstein, on depreciation of health in 
orthostatic albuminuria, 569. 

Lord, on leukocytosis in influenza, 310. 

Lovett, table by, showing increase in 
epidemic form of acute anterior polio- 
myelitis. 

Lumbar puncture, diagnostic value of, 
37; in differentiating the types of 
meningitis, 640; in meningococcic 
meningitis, 634; method of, 27; in 
acute anterior poliomyelitis, 651; in 
tuberculous meningitis, 630. 

Lungs, enlargement of , in syphilis, 362; 
tuberculosis of; see Pulmonary tuber- 
culosis. 

Lussatti and Biolchini, isolation of 
fat-splitting ferment by, 106. 

Luthje, on frequency of late systolic 
pulmonary murmur, 507. 

Lymph-adenoma. See HodgMn's dis- 
ease. 

Lymph nodes, enlargement of, in adeni- 
tis, 543; in adenoid disease, 543; in 
diphtheria, 296; in Hodgkin's dis- 
ease, 540, 541; in kidney tumors, 588; 
in leukemia, 530; in mumps, 359; 
in retropharyngeal abscess, 428; in 
rubella, 342; in scarlet fever, 321; in 
status lymphaticus, 547; in syphilis, 
366; in tuberculous affections, 373; in 
whooping cough, 547. 

Lymph nodes, agglutination of, pro- 
ducing tumor masses in neck or abdo- 
men, 547; infection of, in simple 
adenitis, 542; inflammation of, in 
diphtheria, 304. 

Lymph-node tuberculosis. See Tuber- 
culosis. 

Lymphocytosis, in lymph-node tubercu- 
losis, 384; in lymphoid form of leuke- 
mia, 530; in acute poliomyelitis, 649; 
in simple anemia, 523. 

Lymphoid ring, 417, 418. 

Lymphosarcoma, diagnosis between, and 
Hodgkin's disease, 541. 

Lymphoid tissue, irritability of, in 
measles, 342. 



M 



Malaria, 279. 

Malformations of rectum and anus, 
233; atresia of anus, 233; congenital 
absence of the rectum, 233; fissure 
of the anus, 235; polypus of the 
rectum, 234; proctitis, 236; prolapse 



764 



INDEX 



of the rectum, 234; spasm of the anus, 
236. 

Marasmus, 200. 

Massage, 53. 

Mastoiditis, 717. 

Measles, 332; blood changes in, 336; 
complications in, 336, 340; contagious 
period in, 333; convalescent stage in, 
336; definition of, 339; diet in, 339; 
drugs in, 339 ; enanthem stage in, 334 ; 
etiology of, 332; exanthem stage in, 
335; immunity from, 333; incubation 
period in, 333; method of bringing 
out eruption in, 340; microorganism 
in, 332; mortality from, 338; nervous 
symptoms in, 336; pathology of, 338; 
prognosis of, 338; prophylaxis in, 338; 
quarantine in, 339; sequelae of, 337; 
susceptibility to, 332; symptomatol- 
ogy of, 334; temperature curve in, 
335; treatment of, 339; urine find- 
ings of, 336. 

Meat preparations, 129. 

Medical treatment in infancy and 
childhood, 38. 

Meningitis. 626. 

Meningitis, cerebro-spinal. See Men- 
ingitis, meningococcus. 

Meningitis, meningococcus, 631; blood 
picture in, 634; ''carriers" of, 631; 
complications of, 635; course of, 635; 
diagnosis of, 634 ; duration of, 635 ; eti- 
ology of, 631; fever in, 636; micro- 
organism in, 631; mortality from, 635; 
pathology of, 631; prognosis in, 635; 
prophylaxis in, 636; sequelae of, 636; 
serum treatment of, 636; symptoma- 
tology of, 632; symptomatic treatment 
of, 638; treatment of, 636. 

Meningitis, purulent, 638; definition 
of 638; diagnosis of, 639; influenza 
form of, 640; microorganisms present 
in, 639 ; mortality from, 639 ; pneumo- 
coccus form of, 639 ; staphylococcus 
form of, 639; streptococcus form of, 
639 ; symptomatology of, 639 ; treat- 
ment of, 640; typhoid form of, 640. 

Meningitis, tuberculous, 626; diagno- 
sis of, 629; fever in, 628; microor- 
ganisms in, 630; mortality from, 627; 
pathology of, 626; prognosis of, 630; 
symptomatology of, 627; treatment of, 
630. 

Meningocele, 621. 

Menstrual irregularities in tubercu- 
losis, 383. 

Mental precocity, association of, with 
physical development, 7, 8, 9. 



Mercury, inunction of, in syphilis, 370. 

Microblasts, 516. 

Microcephalic idiocy, 625; treatment 
of, 626. 

Microcytes, 515; in chlorosis, 527; in 
pseudoleukemia, 525. 

Migraine, 258. 

Milk, condensed, 125; cause of rickets, 
237; cause of scurvy, 246; value of, 
as artificial food, 126. 

Milk, breast. See Milk, human. 

Milk, cow's, 118; carbohydrates in, 
135, 137; casein in, 135; "certified," 
119; cleanliness in care of, 118; com- 
position of, 137; fat in, 135, 137; 
food value of, 100; home modification 
of, 135; inorganic constituents of, 
104; inspection of, 118; laboratory 
modification of, 141; malted, 128; 
pasteurization of, 120; pathogenic or- 
ganisms transmitted by, 177; pepto- 
nization of, 121; poisoning by, in in- 
testinal indigestion, 176; use of, with 
premature infants, 68; raw, a cause of 
scurvy, 247; Eotch method of modify- 
ing, 141; skimmed, 124; sterilization 
of, 119; sugar in, 135; tuberculosis 
transmitted by, 376; typhoid fever 
transmitted by, 268, 275. 

Milk diet, effect of, on orthostatic al- 
buminuria, 570; in measles, 339; in 
acute nephritis, 580; in scarlet fever, 
329; in typhoid fever, 276. 

Milk, human, advantages of, in enteric 
infection, 193, 195; advantages of, in 
summer heat, 181; alexins in, 107; 
caloric value of, 102; carbohydrates 
in, 103; casein in, 102; composition 
of, 107; composition of colostrum in, 
108; digestive ferments in, 106; ec- 
zema associated with, 722; effect of 
nursing upon, 113; fat in, 100; food 
value of, 101; gastrointestinal indi- 
gestion associated with, 175; impor- 
tance of, in bronchopneumonia, 465; 
importance of, in infantile atrophy, 
200; importance of, to premature in- 
fants, 67; importance of, in pseudo- 
leukemia, 526; importance of, in syph- 
ilis, 309; inorganic constituents of, 
104; modification of, 111; proteins in, 
102; relation of, to human feeding, 
100; sugar in, 103; water in, 105; 
wholesomeness of, determined, 105. 

Milk, malted, 128; a cause of rickets, 
237, 243; in diet of typhoid fever, 
274. 

Milk of magnesia, therapeutic use of, 



INDEX 



765 



in eczema, 722; in acute nephritis, 
579 ; in pseudoleukemia, 526. 
Milk, modified, 135; value of, in syph- 
ilis, 369. 
Milk, pasteurized, 120; scurvy due to, 

246. 
Milk, peptonized, 121; value of, in 

pseudoleukemia, 526. 
Milk, sterilized, 119; scurvy due to, 

246. 
Milk sugar, intestinal indigestion due 
to, 103, 125; proportion of, in cow's 
milk, 103 ; proportion of, in human 
milk, 103; value of, in artificial feed- 
ing, 125. 
Miliary tuberculosis, 387; treatment 

of, 401. 
Mills, on movements of the eyes in in- 
fants, 690. 
Mineral salts, necessity of, to nutri 

tion, 105; presence of, in milk, 104. 
Minor, on the geographical distribution 

of scarlet fever, 316. 
Mitral regurgitation, 499 ; association 
of, with mitral stenosis, 501; progno- 
sis of, 502; treatment of, 503. 
Mitral stenosis, 500; association of, 
with mitral regurgitation, 501; prog- 
nosis of, 502; treatment of, 503. 
Mixed feeding, 114; use of, in hot 

weather, 181. 
Mongolian idiocy, 624; diagnosis be- 
tween, and idiocy of cretinism, 554; 
treatment of, 625. 
Monoplegia, 614. 
Monsel's solution, 540. 
Monti, on temperature of milk in in- 
fant feeding, 120. 
Moro tuberculin test, diagnostic value 
of, 36; in lymph-node tuberculosis, 
385; in tuberculous meningitis, 627, 
629 ; technique of, 36. 
Morphin, therapeutic use of, in chorea, 
701; in acute cardiac dilatation, 498; 
in eclampsia, 683; in acute endocardi- 
tis, 493; in enteric infection, 195; in 
Henoch's purpura, 587; in intestinal 
hemorrhage in typhoid fever, 278; in 
intestinal indigestion, 188; in kidney 
tumor, 589 ; in meningococcic menin- 
gitis, 638; in acute nephritis, 580, 581; 
in acute pericarditis, 513; in purulent 
meningitis, 640 ; in recurrent vomit- 
ing, 256; in variola, 348; in whooping 
cough, 294. 
Morse, on gastrointestinal indigestion 
as a cause of toxic nephritis, 572; on 
indirect contagion in whooping-cough, 



287; on temperature curve in typhoid 
fever, 270; on toxic nephritis in pneu- 
monia and meningitis, 572. 

Mortality, in appendicitis, 227; in 
bronchopneumonia, 464; causes of, in 
infancy, 1 ; in congenital dilatation 
of the colon, 209; in congenital hyper- 
trophy of the pylorus, 169; in cysto- 
pyelitis, 586; in diphtheria, 301; in 
diplegia, 615; in Hodgkin's disease, 
542; in hydrocephalus, 618, 620; in 
kidney tumor, 589 ; in lobar pneu- 
monia, 449 ; in measles, 388 ; in 
meningococcic meningitis, 635 ; in 
paraplegia, 615; in acute anterior 
poliomyelitis, 650; among premature 
infants, 65; reduction of, in diph- 
theria, under antitoxin treatment, 302 ; 
reduction of, in meningitis under 
Flexner serum, 637; reduction of, in 
small-pox under vaccination, 350; in 
scarlet fever, 325 ; in septic endocardi- 
tis, 491; in septic infection of new- 
born, 79; in status lymphaticus, 548; 
in stomatitis gangrenosa, 153 ; in 
tetanus neonatorum, 91; in tubercu- 
lous meningitis, 627, 630; in typhoid 
fever, 275; in ulcerative endocarditis, 
494; in variola, 350; in whooping 
cough, 291. 

Movements, passive and arrested, 
therapeutic uses of, 53. 

Mucous patches in the new-born, 
363, 364. 

Mucus, swallowing of, a cause of in- 
testinal disorders, 177. 

Mumps, 357; complications of, 359; con- 
tagious period in, 358; definition of, 
357; diagnosis of, 359; diet in, 360; 
drugs used in, 360; etiology of, 357; 
microorganisms in, 357; orchitis in, 
360; prophylaxis in, 360; sources of 
infection in, 357; symptomatology of, 
358 ; temperature curve in, 359 ; trans- 
mission of, 357; treatment of, 360. 

Murmurs, cardiac, in aortic regurgita- 
tion, 501; in aortic stenosis, 501; in 
acute cardiac dilatation, 496; in 
definite interventricular septum, 487; 
in diagnosis between endocarditis and 
pericarditis, 490; in acute endocardi- 
tis, 490; functional, 507; in mitral 
regurgitation, 499 ; in mitral stenosis, 
561; in myocarditis, 495; in chronic 
pericarditis, 514; in persistent patu- 
lous ductus arteriosus, 488; in scarlet 
fever, 325; systolic, 486; in stenosis 
of the pulmonary artery, 487. 



766 



INDEX 



Murmurs, friction, in acute pericardi- 
tis, 510; in chronic pericarditis, 514; 
in pleurisy, 475. 

Murmurs, hemic, in anemia, 523; in 
chorea, 697, 700; in functional heart 
disease, 508; in habit spasm, 702. 

Murphy, on aspiration for empyema, 
480. 

Muscular contractures, in chorea, 
698; in habit spasm, 702; in infantile 
cerebral palsies, 613, 615; in acute 
anterior poliomyelitis, 646; in tetany, 
686. 

Muscular exercise, therapeutic value 
of, 52. 

Muscular system, development of, 20. 

Musser, on angina sine dolor, 497. 

Mustard plaster, therapeutic use of, 
in lobar pneumonia, 451; in pleurisy, 
478; objections to, in broncho-pneu- 
monia, 468. 

Myelocytes, 517; in leukemia, 530; in 
pernicious anemia, 529. 

Myelitis, 653; definition of, 653; dis- 
seminated forms of, 656; etiology of, 
653; microorganisms in, 653; paraly- 
sis in, 654, 655; prognosis of, 655; 
serum treatment of, 656; symptoma- 
tology of, 653; syphilitic, 655, 657; 
temperature curve in, 656; transverse 
forms of, 653; tuberculous form of,, 
655, 656. 

Myocarditis, 494; as cause of acute 
cardiac dilatation, 496; as complica- 
tion of bronchopneumonia, 463 ; as 
complication of acute articular rheu- 
matism, 404; etiology of, 494; inter- 
stitial form of, 495; parenchymatous 
form of, 495; prognosis of, 495; 
prophylaxis of, 497; symptomatology 
of, 495; treatment of, 498. 

Myxedema. See Endemic cretinism. 

N 

Nasal douche, 47. 

Nasal obstructions, pavor nocturnus 
due to, 672, 675. 

Nasal mucous membrane, diseases of, 
411. 

Nasal sinuses, disease of, 448. 

Nauheim baths, in treatment of valvu- 
lar heart disease, 505. 

Neisser's gonococcus. See Gonococcus 
of Neisser. 

Neoplasms of larynx, 435. 

Nephritis, acute, 571; albuminuria in, 
576; casts in, 576; complications in, 
577; as complication of diphtheria, 



300; as complication of purpura, 534, 
535; as complication of scarlet fever, 
324; course of, 577; definition of, 570; 
diet in, 580; dropsy in, 576; drugs 
used in treatment of, 581; idiopathic 
form of, 576; microorganisms present 
in, 571; mycotic form of, 574; pro- 
phylaxis, 578; sources of infection in, 
572; symptomatology of, 575; tempera- 
ture curve in, 577; toxic form of, 572; 
treatment of, 578; uremia in, 576; 
urine findings in, 576; varieties of, 
572. 

Nephritis, chronic diffuse, 582; treat- 
ment of, 582. 

Nephritis, mycotic, 574. 

Nephritis, toxic, 572; treatment of, 
573. 

Nerves, diseases of peripheral, 661. 

Nervous diseases, general, 669. 

Nervous disturbances, in adenoid dis- 
ease, 425; in anemia, 523; in chloro- 
sis, 527; in congenital idiocy, 623; in 
enteric infection, 192; eruption of 
permanent teeth accompanied by, 146 ; 
in influenza, 310; in acute intestinal 
indigestion, 184; mother's milk af- 
fected by, HI; in acute nephritis, 
581; in purpura, 532; in rickets, 240; 
in scarlet fever, 325; in septic infec- 
tion, of new-born, 78; due to thyroid 
intoxication, 557, 558; in typhoid 
fever, 272; due to uric acid, 562. 

Nervous system, development of, 23; 
excessive activity injurious to, 6; im- 
perfect development of, in premature 
infants, 62; shock to, dangerous in 
status lymphaticus, 550. 

Nestle 's food, 127; advantages of, in 
summer, 181; use of, in acute gastri- 
tis, 162; use of, in chronic gastritis, 
173; use of, in intestinal indigestion, 
178; rickets caused by, 237, 243; use 
of, in typhoid fever, 277. 

Netter, on pneumococcus, as cause of 
pleurisy in child, 470. 

Neuritis, multiple, 661; definition of, 
661; diagnosis of, 663; diet in, 663; 
drugs used in treatment of, 663; eti- 
ology of, 661; pathology of, 661; 
symptomatology of, 662; treatment of, 
663. 

Neuritis, optic, as symptom of brain 
abscess, 618; as symptom of brain 
tumor, 617. 

Neurotonic reaction, 688. 

Neutrophiles, 517. 

New-born infant, albuminuria in, 568; 



INDEX 



767 



asphyxia in, 69; bronchopneumonia in, 
464; care of, 2; cephalhematoma in, 
97; clothing of, 5; congenital atelec- 
tasis in, 75 ; congenital hernia in, 86 ; 
congenital syphilis in, 83, 361; derma- 
titis exfoliativa in, 79 ; diseases of, 
69; eclampsia in, 680, 681; epidemic 
hemoglobinuria in, 82, 564; epistaxis 
in, 415; erysipelas in, 80; eyes in, 3; 
facial paralysis in, 98 ; acute fatty 
degeneration in, 83; fresh air neces- 
sary for, 4; gonococcus vulvovaginitis 
in, 591; heat-regulating apparatus in, 
25; hematoma of sterno-cleido-mastoid 
muscle in, 98; hematuria in, 563; 
hemorrhage in, 81; icterus in, 92; in- 
anition fever in, 87; incontinence of 
urine in, 561; mastitis in, 87; melena 
neonatorum in, 82; nervous system in, 
23 ; occlusion of bile-ducts in, 93 ; oph- 
thalmia in, 94; peculiarities of respira- 
tory apparatus in, 410; rest for, 4; 
sepsis in, 263; sleep for, 671; special 
senses in, 22; septic infections in, 
75; structure of spine in, 19; sup- 
pression of urine in, 561; temperature 
in, 25; tetanus in, 89; typhoid fever 
in, 269; umbilical affections in, 84; 
umbilical hernia in, 85; weight of, 15. 

Night-terror, 672; symptomatology of, 
674; treatment of, 675. 

Nipples, care of, 113; in stomatitis 
mycosa, 149. 

Nitre paper inhalation of fumes from, 
in asthma, 712. 

Nitroglycerin, therapeutic use of, in 
asthma, 712; in acute cardiac dilata- 
tion, 498 ; in lobar pneumonia, 463. 

Noma. See Stomatitis gangrenosa. 

Normoblasts, 515. 

Northrup, experiments by, showing 
danger of food pneumonia, 306; on 
fresh air in bronchopneumonia, 465; 
on fresh air in lobar pneumonia, 450; 
on fresh air as therapeutic measure, 
43, 44; on rest cure in neurotic dis- 
turbances, 53; on scurvy in infants, 
246; on sleeplessness in infants, 4. 

Nose, disease in accessory sinuses of, as 
complication of lobar pneumonia, 448; 
disinfection of, a protection against 
recurring attacks of endocarditis, 493; 
foreign bodies in, 416; removal of dis- 
eased tissue from, a protection against 
tuberculosis, 395; ulceration of, in late 
hereditary syphilis, 367. 

Nursery, 5. 

Nursing of infants, adenoid growths 
50 



an obstacle to, 426; retropharyngeal 
abscess, an obstacle to, 428; rules for, 
113. 

Nux vomica, tincture of, therapeutic 
use of, in asthma, 713; in acute endo- 
carditis, 494. 

Nystagmus and head-nodding, 689; 
character of movements in, 689 ; defi- 
nition of, 689; etiology in, 690; prog- 
nosis in, 691; treatment of, 691. 



Obscure fever, 263; use of antipy- 
retics in, 266; diet in, 266; inanition 
fever a cause of, 263; intestinal toxe- 
mia a cause of, 265; lobar pneu- 
monia a cause of, 264; otitis media 
a cause of, 264; pyelocystitis a cause 
of, 264; sepsis a cause of, 263; septic 
infection a cause of, 265 ; treatment of, 
265; tuberculosis a cause of, 264; ty- 
phoid fever a cause of, 265. 

O'Dwyer, Dr. Joseph, on intubation 
for relief of laryngeal diphtheria, 305. 

O'DWYER INTUBATION SET, 305. 

Oilskin jacket, use of, in broncho- 
pneumonia, 468; use of, in acute 
catarrhal bronchitis, 442; contraindi- 
cations to, in lobar pneumonia, 451. 

Ointments in treatment of eczema, 
724. 

Oligochromemia, 516. 

Oligocythemia, 516. 

Ophthalmia, diphtheritic, 299. 

Ophthalmia neonatorum, 94; diagno- 
sis of, 95; etiology of, 94; prognosis 
of, 96; prophylaxis in, 96; symptoma- 
tology of, 95 ; treatment of, 96. 

Opisthotonos, in lobar pneumonia, 449 ; 
in meningococcus meningitis, 632; in 
tuberculous meningitis, 628. 

Opium, therapeutic use of, in appendi- 
citis, 227; in brain abscess, 618; in 
acute endocarditis, 493; in enteric in- 
fection, 195; during infancy, 40; in 
influenza, 314; in acute intestinal in- 
digestion, 188; in kidney tumor, 589; 
in lobar pneumonia, 453 ; in menin- 
gococcic meningitis, 638; in peritoni- 
tis, 232; in acute anterior poliomye- 
litis, 651; in recurrent vomiting, 256; 
in typhoid fever, 278; in whoopiug- 
cough, 294. 

Opium, contraindications to use of, in 
bronchopneumonia, 467; in cough of 
tuberculosis, 400; in measles, 340; in 
multiple neuritis, 664. 

"Opsonins," 55. 



768 



INDEX 



Opsonic index, 56. 

Orange juice, use of, in constipation, 
206, 207; in diet of infants, 137, 142, 
143 j in scurvy, 249; in typhoid fever, 
277. 

Orchitis, as complication of mumps, 
359. 

Orthopedics, in treatment of hemi- 
plegia, 615; in treatment of hereditary 
ataxia, 658. 

Orthostatic albuminuria, 568; defini- 
tion of, 568; diet in, 570; etiology of, 
569; prognosis of, 570; symptomatol- 
ogy of, 569; treatment of, 570; urine 
findings in, 569. 

Osler, on appearance of skin in He- 
noch's purpura, 534; on aspiration in 
acute pericarditis, 513; on cardiac 
murmurs in chorea, 700; on cause of 
pain in Henoch's purpura, 534; on 
sarcomatous nature of kidney tumors 
in child, 587; on typhoid fever in 
autumn, 268. 

Osteochondritis, syphilitic, 362. 

Osteomyelitis, acute, as complication 
of bronchopneumonia, 463; as compli- 
cation of lobar pneumonia, 448; mis- 
taken for articular rheumatism, 405. 

Otitis, chronic, in late hereditary syph- 
ilis, 367. 

Otitis interna, headache from, 709. 

Otitis media, 714; due to adenoid dis- 
ease, 425; brain abscess caused by, 
617, 618; bronchopneumonia compli- 
cated by, 463; acute catarrhal bron- 
chitis, complicated by, 439; diphtheria 
complicated by, 300; etiology of, 714; 
facial paralysis caused by, 664, 665; 
influenza complicated by, 311; inter- 
mittent fever caused by, 715; lobar 
pneumonia complicated by, 448; mas- 
toiditis caused by, 717; microorgan- 
isms present in, 714; mumps compli- 
cated by, 359; obscure fever caused 
by, 264; operative treatment for, 716; 
otoscopic examination in, 715; prog- 
nosis of, 716; prophylaxis of, 716; 
scarlet fever complicated by, 324, 331; 
sources of infection in, 714; symp- 
tomatology of, 714; temperature curve 
in, 715; tonsillitis complicated by, 
419; treatment of, 716; typhoid fever 
complicated by, 274. 

Out-door play, therapeutic value of, 54. 

Ovaritis, as complication of mumps, 
359. 

Over-feeding, as a cause of indigestion 
in infancy, 133, 175. 



Oxybutyric acid, presence of, in urine, 
565. 

Oxalic acid, excess of, in urine in 
orthostatic albuminuria, 569. 

Oxygen, inhalation of, in asphyxia 
neonatorum, 73, 74; in bronchopneu- 
monia, 466; in lobar pneumonia, 453; 
in tuberculous bronchopneumonia, 466. 

Oxyuris vermicularis, 217; diagnosis 
of, 218; treatment of, 218. 



Packs, cold, use of, in lobar pneu- 
monia, 451; objections to, in acute 
catarrhal bronchitis, 442; use of, in 
obscure fevers of childhood, 267; re- 
stricted use of, in bronchopneumonia, 
468; use of, in scarlet fever, 329; 
temperature of, 45; therapeutic value 
of, 45; use of, in typhoid fever, 277. 

Packs, hot, use of, in acute nephritis, 
579. 

Packard, Dr. Frederick, on tonsillitis 
preceding endocarditis, 490; on ton- 
sillitis preceding infectious diseases, 
417. 

Padded basket, use of, for premature 
infants, 66. 

Palate, destructive ulceration of, in late 
hereditary syphilis, 367. 

Palpation, value of, in physical exami- 
nation, 30. 

Paracentesis, in ascites due to valvular 
heart disease, 506; in otitis media, 
716. 

Paralysis, cardiac, in diphtheria, 299; 
in multiple neuritis, 663. 

Paralysis, facial, 664; diagnosis of, 
665; drugs in, 666; etiology of, 664; 
in new-born, 97; operative treatment 
for, 666; in acute anterior polio- 
myelitis, 645; prognosis of, 665; 
symptomatology of, 664; treatment of, 
666. 

Paralysis, motor, in hysteria, 705; in 
multiple neuritis, 662; in myelitis, 
654; in acute anterior poliomyelitis, 
647; in spina bifida, 660. 

Paralysis, post-diphtheritic, 299, 307. 

Paralysis, pseudo, in syphilis, 365. 

Paralysis, splanchnic, in diphtheria, 
299, 307; in influenza, 312, 314; in 
lobar pneumonia, 448. 

Paraphimosis, 596. 

Paraplegia, 614; treatment of, 615. 

Parasites, intestinal, 211; ascaris 
lumbricoides, 215 ; bothriocephalus 






INDEX 



69 



latus, 212; hymenolepis nana, 212; oxy-- 
uris vermicularis, 217; tenia elliptica, 
213; tenia saginata, 211; tenia soli- 
um, 212; trichuris trichiura, 217. 

Parathyroid metabolism, defect in, a 
cause of muscle spasm, 686. 

Paratyphoid fever, diagnosis between, 
and typhoid, 275. 

Paregoric, therapeutic use of, for cough 
in measles, 339; in earache, 716; in 
enteric infection, 195; in acute gastri- 
tis, 162; in acute intestinal indiges- 
tion, 188 ; in kidney tumor, 689 ; in 
lobar pneumonia, 463; in pleurisy, 
478; in tuberculous peritonitis, 410; 
in typhoid fever, 278; in whooping- 
cough, 294. 

Park, Dr. W. H., on diphtheria in ani- 
mals, 295; on management of tene- 
ment houses, 182. 

Parke, Dr. Thomas D., on recurrent 
vomiting, 255. 

Parotitis, epidemic. See Mumps. 

Parotitis, as complication of typhoid 
fever, 274, 276. 

Pasteurized milk, 120. 

Patellar reflex, examination of, in ill- 
ness, 31; in diphtheria, 299. 

Pavor nocturnus, 671; central type of, 
672; clinical pictures of, 674; defini- 
tion of, 671; etiology of, 671; excit- 
ing causes of, 672; predisposing 
causes of, 671; prognosis of, 675; 
symptomatic type of, 674; symptoma- 
tology of, 672; treatment of, 675. 

Pavy, on orthostatic albuminuria, 568. 

Peacock and Keith, on stenosis of pul- 
monary artery, 487. 

Pediculosis capillitii, 736; treatment 
of, 737. 

Pemphigoid ulcerations, as complica- 
tion of measles, 338. 

Pemphigus neonatorum, 732; diagnosis 
between, and syphilitic pemphigus in 
new-born, 364; treatment of, 733. 

Pemphigus, syphilitic, 364. 

Pepsin, elixir of, as vehicle for drugs, 
39; essence of, as vehicle for drugs, 
39. 

Percentage feeding, value of, 129. 

Percentages in food formulas, 139. 

Percussion, value of, in physical exami- 
nation of child, 32. 

Pericarditis, acute, 509; complicating 
acute articular rheumatism, 404; com- 
plicating bronchopneumonia, 463; 
course of, 512; definition of, 509; 
diagnosis of, 511; diet in, 512; eti- 



ology of, 509; complicating Henoch's 
purpura, 534; complicating lobar 
pneumonia, 448; microorganisms pres- 
ent in, 509 ; operative treatment for, 
513; pathology of, 509; physical signs 
of, 510; prognosis of, 512; prophy- 
laxis of, 512; sources of infection in, 
509; temperature curve in, 510; treat- 
ment of, 512; varieties of, 509. 

Pericarditis, chronic, 513; diagnosis 
of, 514; etiology of, 514; physical 
signs in, 514; results of, 514; symp- 
tomatology of, 514; treatment of, 514. 

Periesophageal abscess, 157. 

Peroneal type of progressive muscu- 
lar dystrophy, 668. 

Perinephritis, 590. 

Periostitis, due to late hereditary syph- 
ilis, 367. 

Peritonitis, acute, 228; complicating 
appendicitis, 229; etiology of, 228; 
exciting causes of, 228; complicating 
lobar pneumonia, 448; microorganisms 
present in, 228 ; pathology of, 229 ; 
physical examination in, 231; progno- 
sis of, 231; symptomatology in, 229; 
temperature curve in, 230; treatment 
of, 231. 

Peritonitis, tuberculous, diagnosis of, 
390; pathology of, 381; treatment of, 
401. 

Peritonsillar abscess, 421. 

Perleche, 154; treatment of, 155. 

Permanganate of potash. See Potas- 
sium permanganate. 

Pernicious anemia, 528. 

Peroxid of hydrogen, therapeutic use 
of, in acute anterior poliomyelitis, 
651; in tonsillitis, 423; in umbilical 
infection of the new-born, 80. 

Persistent patulous ductus arterio- 
sus, 488. 

Pertussis. See Whooping-Cough. 

Peterson, on rotary head movements in 
infants, 689. 

Petit mal, 692. 

Pfaundler, on agglutination reaction in 
cystopyelitis, 584. 

Pfeiffer, discovery by, of influenza 
bacillus, 308, 309. 

Pfeiffer 's bacillus. See Influcn-a 
bacillus. 

Pharyngitis, in adenoid disease, 425 ; 
in influenza, 310; preceding acute 
laryngitis, 430; in acute rhinitis, 413. 

Pharynx, destructive ulceration of, in 
late hereditary syphilis, 367 ; diseases 
of, 424; removal of diseased tissue 



770 



INDEX 



from, a protection against tuberculo- 
sis, 395. 
Phenacetin, therapeutic use of, contra- 
indicated in bronchopneumonia, 467; 
in acute catarrhal bronchitis, 441; in 
fevers of infancy and childhood, 267; 
in headache, 710; in influenza, 313; 
in kidney tumor, 589; in lobar pneu- 
monia, 452; in malaria, 286; in 
measles, 340; in mumps, 340; in mul- 
tiple neuritis, 664; in acute anterior 
poliomyelitis, 651; in rubella, 343; in 
tonsillitis, 278; in tuberculosis, 400; 
contraindicated in typhoid fever, 278; 
in varicella, 357; in urticaria, 727. 
Phimosis, 596; association of, with 
enuresis, 599, 601 ; association of, 
with pseudomasturbation, 608. 
Phosphate of soda. See Sodium phos- 
phate. 

Phosphorus, presence of, in milk, 104; 
therapeutic use of, in rickets, 245; 
toxic nephritis due to, 573, 575; uses 
of, to body, 105. 

Physical examination, of sick child, 
29. 

Physical signs, in aortic regurgitation, 
501; in aortic stenosis, 501; in ap- 
pendicitis, 224; in acute bronchitis, 
240; in bronchopneumonia, 460; in 
acute cardiac dilatation, 496; in fail- 
ure of compensation, 502; in intesti- 
nal intussusception, 221; in lobar 
pneumonia, 458, 460; in lymph-node 
tuberculosis, 384; in mitral regurgi- 
tation, 499; in mitral stenosis, 501; in 
myocarditis, 495; in acute pericardi- 
tis, 510; in chronic pericarditis, 514; 
in peritonitis, 231; in pleurisy with 
effusion, 472; in splenic enlargement, 
551; in sporadic cretinism, 553; in 
thyroid enlargement, 547; in tubercu- 
lous bronchopneumonia, 388, 462. 

Physiological albuminuria, 567. 

Physiological gastric incompetency, 
158. 

Pica, 704; treatment of, 705. 

Pick's disease, 514. 

"Pink eye," 413. 

Plasmodium malarle, 279. 

Playgrounds, hygienic value of, 10. 

Pleurisy, 470 ; aspiration for, 479 ; com- 
plicating bronchopneumonia, 462; defi- 
nition of, 470; diet in, 478; displace- 
ment of organs in, 475, 476; drugs 
used in treatment of, 478, 479; with 
effusion, 471, 473; etiology of, 470; 
exploratory puncture in, 476; fluoro- 



scopic examination in, 476; forms of, 
471; complicating lobar pneumonia, 
448; microorganisms present in, 470; 
pain in, 473; pathology of, 471; phys- 
ical signs in, 475; respiration in, 473; 
sources of infection in, 470; surgical 
treatment of, 479; symptomatology 
of, 472; temperature curve in, 472; 
treatment of, 472; treatment of, dur- 
ing convalescence, 482; X-ray picture 
in, 476. 

Pneumococcus peritonitis, 228, 231, 
232. 

Pneumococcus vaccine, therapeutic use 
of, 58. 

Pneumonia, broncho-. See Broncho- 
pneumonia. 

Pneumonia, deglutition, 462. 

Pneumonia, food, risk of, after intuba- 
tion in laryngeal diphtheria, 306. 

Pneumonia, lobar, 442; antipyretics in, 
451; auscultation in, 448; blood 
changes in, 447; complications in, 448; 
cough in, 448; crisis in, 445; danger 
from, in infancy, 6; diet in, 450; dif- 
ferential diagnosis in, 449; drugs in, 
452; etiology of, 442; hygienic treat- 
ment of, 450; local applications in, 
451; complicating measles, 337; medi- 
cal treatment of, 452; microorganisms 
present in, 442; mortality from, 2, 
449; obscure fevers in infancy due to, 
264; pathology of, 443; percussion in, 
448; physical signs in, 447; prognosis 
of, 449; respiration in, 446; sources 
of infection in, 443; stimulants in, 
451; symptomatology of, 444; tem- 
perature in, 261, 444, 445; treatment 
of, 449; treatment of, during conva- 
lescence, 453; complicating typhoid 
fever, 274; urine findings in, 447; 
complicating whooping-cough, 294. 

POIKILOCYTOSIS, 516. 

Poisons, irritant, cause of enterocol- 
itis, 189; cause of hemoglobinuria, 
564. 

Polioencephalitis. See Acute anterior 
poliomyelitis. 

Poliomyelitis, acute anterior, 641; 
abortive type, 645; ataxic type, 646; 
bulbar type, 645; chronic changes in, 
644; definition of, 641; descending 
type of, 645; diagnosis of, 649; elec- 
trical reactions in, 649; encephalitic 
type, 646; epidemic form of, 642; eti- 
ology of, 641; immunity from, 644; 
meningeal type, 646; mortality from, 
650; muscular atrophy in, 648; paral- 



INDEX 



771 



ysis in, 647; pathology of, 643; poly- 
neuritic type, 647; pontine type, 645; 
prophylaxis of, 651; prognosis of, 650; 
sources of infection in, 642; spinal 
poliomyelitic type, 646; sporadic form 
of, 642; symptomatology of, 644: 
transmission of, 641; treatment of, 
651; treatment of paralysis in, 652; 
use of urotropin in, 651. 

polychromasia, 516. 

Polycythemia, 516. 

Polypnea in young children, 27. 

Polypus of the rectum, 234. 

Porter, W. T., on comparative rate of 
growth in children at public schools, 
16; on physical basis of precocity and 
dullness, 7. 

Porter and Fleischner, report of re- 
current vomiting associated with cysto- 
pyelitis, 585. 

Position, significance of, in examination 
of sick child, 30. 

Postural albuminuria. See Orthosta- 
tic albuminuria. 

Postnatal palsies, 611. 

Potassium acetate, therapeutic use of, 
in pleurisy with effusion, 478. 

Potassium bicarbonate, therapeutic use 
of, in enuresis, 602. 

Potassium carbonate, therapeutic use 
of, in urethritis in male child, 596. 

Potassium chlorate, hemoglobinuria 
caused by, 564; hematuria caused by, 
563 ; purpura caused by, 532 ; thera- 
peutic use of, in stomatitis ulcerosa, 
151; toxic nephritis caused by, 573, 
575. 

Potassium citrate, therapeutic use of, 
in cystopyelitis, 586. 

Potassium iodid, therapeutic use of, in 
brain tumors, 617; in hydrocephalus, 
620. 

Potassium permanganate, therapeutic 
use of, in gonococcus vulvovaginitis, 
594. 

Pott's disease, 391; examination for, 
31; myelitis as complication of, 653, 
654, 655, 656. 

Poverty, tuberculosis a cause of, 375. 

Poynton, on presystolic murmur in mi- 
tral regurgitation, 500. 

Premature infants, 62; artificial feed- 
ing for, 68; breast feeding for, 67; 
digestive system in, 64; feeding of, 
67; heat-regulating mechanism, 25, 62; 
hereditary disease in, 64; incubator 
for, 66; nervous system in, 62; pad- 
ded basket for, 66; physical peculiari- 



ties of, 62; prognosis for, 65; quanti- 
ty of food for, 68; susceptibility to 
reinfection in, 64; treatment of, 65; 
weight of, 65; wet nurse for, 68. 

Prenatal palsies, 610. 

Prepuce, adherent, 596; enuresis asso- 
ciated with, 599, 601; pseudomastur- 
bation associated with, 608. 

Pressure signs :n lymphnode tuber- 
culosis, 385. 

Priessnitz's application, in treatment 
of bronchopneumonia, 468; in treat- 
ment of lobar pneumonia, 451. 

Proctitis, 236. 

Prolapse of rectum, 234. 

Progressive muscular dystrophy, 666; 
definition of, 666 ; Erb 's juvenile type 
of, 668 ; etiology of, 666 ; Landouzy- 
Dejerine type of, 668; peroneal type 
of, 668; pseudohypertrophic type of, 
666; symptomatology of, 666; treat- 
ment of, 669. 

Proprietary foods, 127; in causation of 
rickets, 237; in causation of scurvy, 
246; value of, in artificial feeding, 
127; value of, in chronic gastritis, 
172; value of, in hot weather, 182; 
value of, in typhoid fever, 277. 

Protein, digestibility of, 135 ; indiges- 
tion from, 186; nutritional value of, 
103; proportion of, in beef juice, 129; 
proportion of, in broth, 129; propor- 
tion of, in buttermilk, 122, 123; pro- 
portion of, in Finkelstein 's albumin 
milk, 123 ; proportion of, in malt 
soups, 124; proportion of, in milk, 
101; proportion of, in skimmed milk, 
124. 

Proteus vulgaris, in causation of en- 
teric infection, 178. 

Pryor, on development of bony frame- 
work in child, 19. 

Pseudo-diphtheritic bacillus, in caus- 
ation of simple vulvovaginitis, 595. 

PSEUDO-HYPERTROPHIC FORM OF PROGRES- 
SIVE MUSCULAR DYSTROPHY, 666. 

Pseudoleukemia of infants, 524; age 
as predisposing factor in, 524; blood 
changes in, 525; definition of, 524; 
diet in, 526; differential diagnosis in, 
525; drugs used in treatment of. 526; 
etiology of, 524; prognosis of, 526; 
symptomatology of, 525; temperature 
curve in, 525 ; treatment of, 526. 

Pseudomasturbatiox, 603; age as etio- 
logical factor in, 604; definition of, 
603; direct causes of, 607; drugs used 
in treatment of, 60$; environment as 



772 



INDEX 



etiological factor, 606; epilepsy not 
related to, 607; etiology of, 604; 
general treatment of, 609 ; habit as 
etiological factor in, 606; mechanical 
treatment of, 609; neurotic inheri- 
tance an etiological factor in, 606; 
prognosis of, 607; sex as an etiologi- 
cal factor in, 606; symptomatology 
of, 603; treatment of, 607. 

Psychic epilepsy, 693. 

Psychotherapy, value of, in nervous 
disorders, 54; in whooping-cough, 
292. 

Puberty, rapid growth in height pre- 
ceding, 17; rapid growth in weight 
preceding, 16; reflex disturbances at, 
13; thyroid gland excessively active 
at, 17. 

Public school system, hygienic defects 
in, 8. 

Pulmonary tuberculosis. See Tuber- 
culosis of the lungs under Tuberculosis. 

Pulse rate, instability of, in infancy, 
484; peculiarities of, in myocarditis, 
495; peculiarities of, in typhoid fe- 
ver, 270; rapidity of, in bronchopneu- 
monia, 457; rapidity of, in pleurisy, 
with displacement of the heart from 
effusion, 473; ratio between, and tem- 
perature in lobar pneumonia, 444. 

Puncture, exploratory, in pleurisy 
with effusion, 476. 

Puncture, lumbar. See Lumbar. 

Purpura, 531; character of eruption in, 
531; definition of, 531; diet in, 535; 
drugs in causation of, 532 ; drugs 
used in treatment of, 536; etiology of, 
532; fulminans, 523, 537; hemorrha- 
gica, 533, 536; Henoch's purpura, 

534, 537; hydrotherapy for, 536; med- 
ical treatment of, 536; rheumatica, 

535, 537; simplex, 532; symptomatica, 
532; temperature curve in p. hemor- 
rhagica, 533; treatment of, 535; treat- 
ment of special forms, 536; varieties 
of, 532. 

" Purpuras, ' ' 531. 

Purulent meningitis. See Meningitis, 
purulent. 

Putnam, on arsenic as cause of neuritis 
in children, 661; on night terror, 673, 
675. 

Pyelitis, diagnosis between, and ma- 
laria, 284. 

Pyemia, diagnosis between, and malaria, 
284. 

Pyelocystitis, as cause of obscure fever 
in infancy, 264. 



Pyramidon, therapeutic use of, in fever 
of tuberculosis, 400. 



Q 



Quarantine, hygienic reasons for, 6; 
length of, in diphtheria, 302; in influ- 
enza, 312; in measles, 339; in mumps, 
358; in acute anterior poliomyelitis, 
651; in rubella, 343; in scarlet fever, 
327; in varicella, 357; in variola, 348; 
in whooping-cough, 288. 

Quassia, use of, for removal of oxyuris 
vermicularis, 218. 

Quinin, therapeutic use of, in asthma, 
713; in chlorosis, 528; in chorea, 701; 
in headache, 710; in influenza, 313; 
in lobar pneumonia, 452; in malaria, 
284; in rhinitis, 415; in tonsillitis, 
422; in whooping-cough, 293; purpura 
caused by, 532. 

Quinsy. See Peritonsillar abscess. 



Eachitis. See EicTcets. 

Radial fissures, 364, 365. 

Radiography. See X-Eay treatment. 

Ransohoff's method for after-treatment 
of empyema, 48. 

" Raspberry excrescence," 353. 

Reactions, electrical, in facial paraly- 
sis, 665; in multiple neuritis, 663; in 
acute anterior poliomyelitis, 649; in 
progressive muscular dystrophy, 667. 

Rectal enemata, therapeutic value of, 
51. 

Rectal feeding, therapeutic value of, 
51. 

Rectal irrigation, therapeutic value of, 
46. 

Rectal suppositories, therapeutic value 
of, 52; in constipation, 207; in scar- 
let fever, 331; in typhoid fever, 278; 
objections to, in artificially fed in- 
fant, 206. 

Rectal temperature, importance of 
taking, in examination of sick child, 
29. 

Rectum, malformation of. See Mal- 
formation. 

Rectum, polypus of, 234. 

Rectum, prolapse of, 234; in enteric 
infection, 191; caused by whooping- 
cough, 289. 

Recurrent coryza, 258. 

Recurrent vomiting, 251; blood 
changes in, 254; climate in treatment 



INDEX 



773 



of, 257; clinical types of, 254; in 
cystopyelitis, 285; definition of, 251; 
diagnosis of, 254; diet in, 254; drugs 
used in treatment of, 255, 256; etiol- 
ogy of, 251; exciting causes of, 251; 
hygiene in treatment of, 257; pain in, 
253; predisposing causes of, 252; 
prognosis of, 254; symptomatology 
of, 252; synonyms for, 251; tempera- 
ture changes in, 253; treatment of at- 
tack of, 255; treatment of interval in, 
256; urine findings in, 254. 

Bed light treatment of small-pox, 
349. 

Reflex centers, imperfect development 
of, in premature infants, 64. 

Reflex irritation, development of geni- 
tal organs a cause of, 13; eclampsia 
due to, 668; eczema due to, 719, 722; 
enuresis due to, 601; epilepsy due to, 
692, 695; headache due to, 709; habit 
spasm due to, 702; hysteria due to, 
705; insomnia due to, 676; laryngis- 
mus stridulus due to, 684; masturba- 
tion due to, 606, 608; nervous strain 
due to, 10, 11, 13; night-terror due to, 
772; tetany due to, 687. 

Reflexes, examination of, in sick child, 
31; in acute anterior poliomyelitis, 
644; in progiessive muscular dystro- 
phy, 607. 

Renal calculi, formation of, in in- 
fants, 562. 

Resorcin, therapeutic use of, in ec- 
zema, 723. 

Respiration, acceleration of, for slight 
causes in infancy, 110; artificial, 72; 
peculiarities of, in child, 410. 

Respiratory centers, imperfect devel- 
opment of, in premature infants, 63. 

Respiratory movements, examination 
of, in sick child, 30. 

Rest, therapeutic value of, 52; in acute 
articular rheumatism, 405; in chorea, 
700; in control of fever in tubercu- 
losis, 400; in eclampsia, 684; in endo- 
carditis, 495; in infancy, 11, 13, 135; 
in hysteria, 768; in myocarditis, 498; 
in new-born, 4; in pericarditis, 535; 
in acute anterior poliomyelitis, 651; 
in tuberculous peritonitis, 101; in val- 
vular heart disease, 505. 

Rest in bed, therapeutic value of, in 
acute nephritis, 580; in multiple neu- 
ritis, 663; contraindicated in ortho- 
static albuminuria, 570. 

Rest cure, indications for, 52. 

Retro-pharyngeal abscess, 427; diag- 



nosis of, 428; microorganisms present 
in, 427; predisposing causes of, 428; 
prognosis of, 429; sources of infection 
in, 427; symptomatology of, 428; tem- 
perature changes in, 428; treatment 
of, 429. 

Reuss, experiments by, on value of dex- 
tri-maltose preparations, 125. 

Rheumatic nodules, 403. 

Rheumatic wry neck, 403. 

Rheumatism, acute articular, 402; 
chorea due to, 404, 697; definition of, 
402; diagnosis of, 404; diet in attack 
of, 405; diet in interval of, 406; drugs 
used in treatment of, 405; erythema 
multiforme due to, 729 ; etiological 
factor in endocarditis, 489; etiology 
of, 402; heart disturbances in, 404; 
heredity in causation of, 402; medical 
treatment of, 405 ; microorganisms 
present in, 402 ; myelitis as sequel to, 
653; prognosis of, 405; salicylates in 
the treatment of, 405 ; simple anemia 
in, 404; sources of infection in, 402; 
symptomatology of, 403 ; temperature 
changes in, 405; tonsillitis in, 404; 
treatment of attack, 405; treatment 
of interval, 406; valvular heart dis- 
ease due to, 498, 503. 

Rheumatism, scarlatinal, 324, 331. 

Rhinitis, acute, 411; adenoid disease a 
cause of, 425; definition of, 411; drugs 
used in treatment of, 415; etiology of, 
411; acute laryngitis following, 430; 
microorganisms present in, 411; proph- 
ylaxis in, 414; prognosis of, 413; 
sources of infection in, 411; sympto- 
matology of, 412; temperature changes 
in, 412, 413; treatment of, 414. 

Rhinitis, chronic, 414; treatment of, 
415. 

Rickets, 237; blood changes in, 242; 
bony deformities in, 241; congenital 
form, 242; course of, 242; curative 
treatment of, 243; definition of, 237; 
diagnosis of, 242; drugs used in treat- 
ment of, 244; eclampsia caused by, 
679 ; gastrointestinal disorders in, 240 ; 
head-sweating in, 240; hernia in, 240; 
general appearance in, 239; late form, 
412; morbid anatomy of, 238; previous 
symptoms in, 240; pathology of, 238; 
prevention of deformities in, 245 ; 
prognosis in, 242; prophylaxis in, 243; 
symptomatology of, 239; treatment of, 
243; treatment of deformities in, 245; 
tetany caused by, 686; weakness of 
ligaments and nmseles due to, 240. 



774 



INDEX 



Ringworm of the tongue. See Geo- 
graphical tongue. 

Roger, on situation of systolic murmur 
in defective interventricular septum, 
487. 

Eomberg and Passler, on splanchno- 
paralysis as a result of pneumococcus 
toxins, 448. 

Romberg's sign, 657. 

Rontgen rays, diagnostic value of, 38; 
in bone and muscle development and 
capacity, 19, 20; in bone and joint 
tuberculosis, 393; in congenital dilata- 
tion of the colon, 209 ; in cystopyelitis, 
586; in demonstration of enlarged thy- 
mus, 547; in foreign bodies in larynx, 
trachea, and bronchi, 437; in infective 
arthritis, 408; in lymph node tubercu- 
losis, 385; in acute pericarditis, 511; 
in pleurisy with effusion, 476; in per- 
sistent patulous ductus arteriosus, 488; 
in spina bifida, 659; in status lym- 
phaticus, 547. 

Rontgen rays, therapeutic value of, in 
Hodgkin's disease, 542; in leukemia, 
531; in status lymphaticus, 548, 549; 
in tinea tonsurans, 735 ; in thyroid en- 
largement, 549; rules for use of, in 
status lymphaticus, 550; technique for 
use of, in thyroid enlargement, 549. 

Rose position, in operation for retro- 
pharyngeal abscess, 429. 

Rose spots, in diagnosis of typhoid fe- 
ver, 271. 

Rotch, on increase in height during first 
month of life, 17; on indications for 
paracentesis in acute pericarditis, 513; 
on lack of conformity between chrono- 
logical age and physical development, 
20; on modification of milk, 141; prac- 
tical system by, for grading work of 
child, 20; on relative frequency with 
which tuberculosis attacks different 
joints, 381; report by, on case of men- 
ingococcic meningitis in infant six 
days old, 631; on Rontgenization of 
wrist bones as indication of bone and 
muscle development in child, 19; on 
structure of spine at birth, 19. 
Rotoh laboratory method of modify- 
ing MILK, 141. 

Rotheln. See Rubella. 

Round worm. See Ascaris lumbricoides. 

Roux, work done by, upon antitoxin, 302. 

Rubella, 341; blood changes in, 343; 
complications in, 343 ; definition of, 
341; drugs used in treatment of, 343; 
enanthem of, 342; etiology of, 341; 



exanthem of, 342; immunity from, 
341 ; incubation period in, 341 ; lym- 
phatic tissue affected in, 342; progno- 
sis of, 343; symptomatology of, 341; 
temperature changes in, 341 ; treatment 
of, 343; urine findings in, 343. 
Rurah, table by, showing causes of noc- 
turnal enuresis, 600; table by, show- 
ing differential diagnosis of acute ex- 
anthemata, 344. 

S 

Sabouraud, on the parasite causing tinea 
tonsurans, 733. 

Sachs, on aphasia associated with left- 
sided hemiplegia, 613; on epilepsy, 
692, 694; on relation of epilepsy to 
early spastic palsies, 613; on surgical 
treatment of epilepsies, 696; table by, 
showing classification of infantile cere- 
bral palsies, 611. 

Salicylate of sodium, therapeutic value 
of, in facial paralysis, 666; in acute 
follicular tonsillitis, 422. 

Salicylates, diagnostic value of, in 
rheumatism, 404; therapeutic value of, 
in acute endocarditis, complicating 
rheumatism, 493; in pleurisy, with 
gout tendencies, 478; in prophylaxis 
of endocarditis, 493; in rheumatism, 
405; in valvular heart disease due to 
rheumatism, 504. 

Salicylic acid ointment, therapeutic 
use of, 42, 43; in congenital ichthyosis, 
731; in eczema, 723; in impetigo con- 
tagiosa, 732; in pleurisy, 479; in tinea 
tonsurans, 734. 

Salol, therapeutic use of, in acute ca- 
tarrhal bronchitis, 441; in chlorosis, 
528; in chorea, 701; in cystopyelitis, 
587; in acute endocarditis, 494; in in- 
fluenza, 314; in pernicious anemia, 
529; in pseudoleukemia, 526; in tonsil- 
litis, 422; in typhoid fever, 277; in 
urethritis in male child, 596; in urti- 
caria, 728. 

Salt baths, therapeutic value of, 46. 

Salvarsan, therapeutic use of, in syphi- 
lis, 372. 

Santonin, therapeutic use of, for ascaris 
lumbricoides, 216; for oxyuris vermi- 
cularis, 218. 

Scabies, 735; treatment of, 736. 

Scarlet fever, 315; antistreptococcic se- 
rum in, 330; cervical adenitis in, 321; 
climatic influences upon, 315; compli- 
cations in, 324; contagious period in, 
317; convalescence from, 332; defini- 



INDEX 



775 



tion of, 315; desquamation in, 322; 
diagnosis of, 325; diet in, 329; drugs 
used in treatment of, 330; eruption in, 
321, 325; etiology of, 315; exciting 
causes of, 316; fulminating type of, 
323; geographical distribution of, 316; 
hydrotherapy in, 329 ; incubation pe- 
riod in, 318; inunctions in, 330, 331; 
irregular clinical types of, 323; ma- 
lignant type of, 323; measles compli- 
cated by, 338; microorganism in, 316; 
mild type of, 323; mortality from, 2, 
325; mycotic nephritis due to, 574; 
pathology of, 317; predisposing causes 
of, 315; prognosis of, 325; prophy- 
laxis of, 327; quarantine in, 327; re- 
currence of, 323; relapses in, 323; sep- 
tic type of, 323; sore throat in, 321; 
sources of infection in, 316; stimu- 
lants in, 329; symptomatology of, 318; 
temperature changes in, 318; tongue 
in, 321; transmission of, 316; treat- 
ment of, 328; treatment of nose and 
throat in, 330; urine findings in, 322; 
vomiting in, 318. 

Scarlatina. See Scarlet fever. 

Schonlein 's disease. See Purpura rheu- 
matica. 

School work, nervous strain of, 8 ; habit 
spasm due to, 702; hysteria due to, 
705; insomnia due to, 676; night-ter- 
ror due to, 672; weight a test of en- 
durance of, 7, 8. 

SCHOTTMUELLER 's DISEASE, 494. 

Schultze's method of artificial respira- 
tion, 72. 

Scorbutus. See Scurvy. 

Scurvy, infantile. See Infantile. 

Seborrhea, character of, 720; treatment 
of, 726. 

Seibert, on humidity affecting mortality 
from intestinal disorders, 180; on ich- 
thyol ointment in scarlet fever, 330. 

Septicemia, complicating diphtheria, 299, 
307; complicating scarlet fever, 323, 
330; diagnosis between, and malaria, 
284. 

Septic arthritis, as a complication in 
scarlet fever, 324. 

Septic infection. See Sepsis. 

Sepsis, diphtheria complicated by, 296; 
fever in second week of life due to, 
263 ; myelitis following, 655 ; obscure 
fevers in childhood due to, 265; pre- 
mature infants liable to, 164. 

Septic infections in new-born, 75; 
diagnosis of, 78; etiology of, 75; in- 
dividual symptoms in, 78; prognosis 



in, 79; sources of infection in, 76; 
symptomatology of, 77. 

Serum, antimeningitic, 636; effect of, 
- upon prognosis, 635; effect of, upon 
sequelae, 635 ; nature of, 60. 

Serum, antistreptococcic, therapeutic 
use of, in diphtheritic septicemia, 307; 
in hemophilia, 540; in acute infective 
myelitis, 657; in measles with septic 
complications, 340; in scarlet fever, 
330; in stomatitis gangrenosa, 153; in 
ulcerative endocarditis, 494. 

Serum, antitoxin, of diphtheria. See 
Antitoxin. 

Serum, standardized animal blood, 
therapeutic use of, in hemophilia, 
540. 

Serum treatment, 59; asthmatic pa- 
tients unsuited for, 713; in diphtheria, 
302, 307; in hemophilia, 540; in acute 
infective myelitis, 657; in measles with 
septic complications, 340; in meningo- 
coccic meningitis, 635 ; rashes from, 
mistaken for scarlet fever, 330; in 
scarlet fever, 330; in stomatitis gan- 
grenosa, 153; in ulcerative endocar- 
ditis, 494. 

Shell-fish, a source of infection in ty- 
phoid fever, 268, 275. 

Shiga bacillus, association of, with gas- 
troenteric affections, 178. 

Silbermann, on types of night-terror, 
672, 673, 674. 

Sight, sense of, in infancy, 22. 

Silver nitrate, therapeutic use of, in 
local treatment of scarlet fever, 330; 
by irrigation, in cystopyelitis, 587; in 
gonococcus vulvovaginitis, 594. 

Silver, colloidal, therapeutic use of, 43. 

Simple secondary anemia, 522. 

Skimmed milk, 124. 

Skin reactions from tuberculin. See 
Tuberculin. 

Skin, inspection of, in illness, 30; itch- 
ing of, in status lymphaticus, 547; 
stimulation of, in acute nephritis, 579. 

Sleep, amount of, necessary in childhood, 
671; amount of, necessary to new- 
born, 4; amount of, necessary to school 
child, 13; disorders of, 669; physi- 
ology of, 669. 

Sleep, disorders of, 669; insomnia, 675; 
night-terrors, 672; pavor nocturnus, 
671; somnambulism, 677. 

Small-pox. See Variola. 

Smith, Eustace, on venous hum in 
functional heart disease, 508; on ve- 



'776 



INDEX 



nous hum in tuberculosis of lymph- 
nodes, 384. 

Snake venom, a cause of purpura, 532. 

Snow, on intestinal intussusception, 220. 

"Snuffles," 363. 

Sodium benzoate, therapeutic use of, in 
acetonuria, 567; in enuresis, 602; in 
influenza, 313; in pseudomasturba- 
tion, 609; in valvular heart disease, 
504. 

Sodium bicarbonate, therapeutic use of, 
567; in artificial feeding, 139; in cys- 
topyelitis, 586; in eczema, 722; in en- 
docarditis, 494; in enuresis, 602; in 
pica, 705; in recurrent vomiting, 256; 
in rheumatism, 405, 406, 407; in urti- 
caria, 727; in valvular heart disease 
due to rheumatism, 504. 

Sodium chlorid, therapeutic use of, in 
artificial feeding, 139; in hemoglobinu- 
ria, 565. 

Sodium citrate, use of, in artificial 
feeding, 139. 

Sodium phosphate, therapeutic use of, 
in eczema, 722; in enuresis associated 
with constipation, 603; in purpura, 
536. 

Sodium salicylate, therapeutic use of, 
in chorea, 701; in facial paralysis, 
666; in pleurisy, 478; in tonsillitis, 
422; in urticaria, 728; in valvular 
heart disease due to rheumatism, 505. 

Sodium sulphate, therapeutic use of, 
in enuresis associated with constipation, 
603; in purpura, 536. 

Somnambulism, 677; treatment of, 678. 

Soper, on use of abdominal belt in 
whooping-cough, 293. 

Southworth, on food percentages, 139. 

"Soxhlet's Nahrzucker, " 125. 

Spasm of anus, 236. 

Spasmophilic diathesis, 687. 

Spanish-American Commission, on in- 
cubation period in typhoid fever, 269. 

Special senses, development of, 22. 

Speech, development of function of, 22. 

Spiegelburg, on food consumption in 
infants, 130. 

Spina bifida, 658; definition of, 658; 
diagnosis of, 660 ; meningocele form 
of, 658; meningomyelocele form of, 
659; prognosis of, 660; syringomyelo- 
cele form of, 660; treatment of, 660. 

Spinal column, examination of, in sick 
child, 31. 

Spinal cord, diseases of, 641. 

Spine and bony framework, develop- 
ment of, 19. 



Spine, curvature of, in school child, 19. 
gymnastic exercises in correction of, 
53. 

Spleen, diseases of, 551, 552. 

Spleen, enlargement of, 551; in ane- 
mias, 522; causes of, 552; clinical 
significance of, 552; diagnosis of, 
551; disorders of malnutrition associ- 
ated with, 552; in Hodgkin's disease, 
541; in acute infectious diseases, 552; 
in leukemia, 531; in malaria, 282; in 
mumps, 359; physical signs of, 551; 
in acute anterior poliomyelitis, 646; 
in pseudoleukemia, 525; in status 
lymphatieus, 545, 547; in syphilis, 
362, 366, 367; in tuberculosis of mes- 
enteric lymph nodes, 383; in typhoid 
fever, 271. 

Splenocytes. See Mononuclear leuTco- 



Splenomegaly, 552. 

Spolverini, on development of amylase, 
105; on digestive ferments present in 
milk, 107. 

Sporadic cretinism. See Cretinism. 

Sprue. See Stomatitis mycosa. 

Squills, objections to use of, in bron- 
chopneumonia, 467; in acute catarrhal 
bronchitis, 441; in lobar pneumonia, 
453. 

Staphylococcus vaccine, therapeutic 
use of, 57. 

Starr, table by, showing nature and po- 
sition of brain tumors, 616. 

St. Anthony's dance. See Chorea. 

Starten's lotion, 723. 

Status lymphaticus, 545; anatomy of, 
545; anesthesia dangerous in, 547; 
blood changes in, 547; definition of, 
545; diet in, 550; drugs used in treat- 
ment of, 550; dyspepsia in, 546; ex- 
ercise in, 550; fresh air in, 550; mor- 
tality in, 548; pathology of, 545; prog- 
nosis of, 548; Eontgen rays in diag- 
nosis of, 547; Eontgen rays in treat- 
ment of, 548; sudden death in, 546; 
surgical treatment of, 550; sympto- 
matology of, 546; thymic asthma in, 
546; thymic enlargement in, 547; 
treatment of, 548. 

Steel, operation by, for obstruction of 
esophagus, 158. 

Sterilized milk, 119. 

Sterility, due to gonococcus vulvova- 
ginitis in infancy, 593. 

Still, on orthostatic albuminuria, 569, 
'570. 



INDEX 



77 



Still's disease. See Chronic rheumatoid 
arthritis. 

Stock vaccines, therapeutic use of, 57. 

Stools, character of, in enteric infection, 
191; in fat indigestion, 185; in acute 
intestinal indigestion, 184; in protein 
indigestion, 186; in sugar indigestion, 
186; therapeutic value of examination 
of, in illness, 34. 

Stomach, diseases of, 158. 

Stomach washing. See Lavage. 

Stomatitis aphthosa, 147; complicat- 
ing measles, 338; treatment of, 148. 

Stomatitis catarrhalis, 146; treatment 
of, 147. 

Stomatitis gangrenosa, 152; treat 
ment of, 153. 

Stomatitis mycosa, 148; treatment of, 
149. 

Stomatitis ulcerosa, 150; treatment 
of, 151. 

Stramonium, inhalation of, in treatment 
of asthma, 712. 

Strapping chest, for relief of pain in 
pleurisy, 478. 

"Strawberry tongue,' ' 321. 

Streptococcus enteritides, as cause of 
enteric infection, 178. 

Streptococcus vaccine, therapeutic use 
of, 58. 

Strophanthus, therapeutic use of, in 
bronchopneumonia, 466; in acute car- 
diac dilatation, 498; in diphtheria, 
307; in acute endocarditis, 494; in 
intestinal hemorrhage of typhoid fever, 
278; in lobar pneumonia, 452; in mea- 
sles, 340; in meningococcic meningi- 
tis, 638; in pleurisy, with effusion, 
478; in scarlet fever, 330; in valvular 
heart disease, 505; in variola, 349; in 
whooping cough, 294. 

Strychnin, therapeutic use of, in as- 
phyxia neonatorum, 73; in broncho- 
pneumonia, 406; in constipation, 208; 
in acute cardiac dilatation, 498; in 
diphtheria, 307; in enuresis, 603; in 
multiple neuritis, 664; in acute peri- 
carditis, 513; in acute anterior polio- 
myelitis, 651; in scarlet fever, 330; in 
valvular disease of the heart, 505. 

St. Vitus' dance. See Chorea. 

Sugar, acid fermentation, due to, in 
food, 125; indigestion due to excess 
of, 135, 186; proportion of, in butter- 
milk, 122, 123; proportion of, in 
Finkelstein 's milk, 123; proportion of, 
in milk, 103 ; proportion of, in skimmed 
milk, 124. 



Suggestion, therapeutic use of, in epi- 
lepsy, 695; in hysteria, 708. 

Sulphate of soda. See Sodium sul- 
phate. 

Sulphur ointment, therapeutic use of, 
in congenital ichthyosis, 731; in im- 
petigo contagiosa, 732; in scabies, 736; 
in tinea tonsurans, 733; in tubercu- 
losis, 729. 

"Summer complaint," 180. 

Suppositories, rectal. See Eectal sup- 
positories. 

Svehla, on theory as to cause of status 
lymphaticus, 545, 546. 

Sydenham's chorea. See Chorea. 

Syphilis, 360; acquired form of, 360, 
361; blood changes in, 366; bones af- 
fected by, 360, 361; brain affected by, 
366; brain tumor due to, 617; com- 
parative value of mercurial prepara- 
tions in treatment of, 371; congenital 
form of, 360, 361; coryza in, 363; 
deafness from, 367; definition of, 
360; diagnosis of, 367; diet in, 369; 
drugs used in treatment of, 370; eti- 
ology of, 361; general malnutrition in, 
365, 367; gummatous ulcerations in, 
367; hydrocephalus due to, 619, 620; 
interstitial keratitis due to, 367; iodin 
in treatment of, 371; kidneys affected 
by, 366; laryngismus stridulus due to, 
685; late hereditary form of, 366; lo- 
cal treatment of, 373; medical treat- 
ment of, 370; mercury internally in, 
370; mercury by inunction, 370; meth- 
od of obtaining blood for examination 
in, 368; microorganism in, 360; myeli- 
tis due to, 655; in new born, 83, 364; 
nose and throat affected by, 367; in 
nursing infants, 112; pathology of, 
362; a predisposing cause of malaria, 
594; prognosis of, 368; prophylaxis 
of, 369; salvarsan in treatment of, 
372; skin lesions in, 364, 367; spleen 
affected by, 366, 367 ; symptomatology 
of, 362; teeth affected by, 46, 365; 
transmission of, 361, 362; treatment 
of, 369; vaccination not a means of 
transmission, 353; Wassermann reac- 
tion in diagnosis of, 368. 
Syringomyelocele, 660. 
Syrup of hydriodic acid, therapeutic 
use of, in asthma, 713; in chronic 
bronchitis, 442; in convalescence from 
bronchopneumonia, 469; in convales- 
cence from acute laryngitis, 433 ; in 
convalescence from lobar pneumonia, 
453. 



78 



INDEX 



Syrup of iodid of iron, therapeutic use 
of, in tuberculosis, 399. 

Syrup of ipecac, therapeutic use of, 
in asthma, 712; in acute catarrhal 
bronchitis, 441; in acute laryngitis, 
432; contrainclicated, in bronchopneu- 
monia, 467; in lobar pneumonia, 453. 

Systemic intoxication, a cause of ob- 
scure fever in infancy, 261, 262. 

Syrups, objections to use of, 40, 340. 



Tachycardia, paroxysmal, 506. 

Tachypnea, in acute cardiac dilatation, 
497. 

Talbot, on microscopical examination of 
stools, 35. 

Tapeworm. See Tenia. 

Tar, therapeutic use of, in eczema, 723. 

Tartar-emetic, objections to use of, in 
bronchopneumonia, 467; in acute ca- 
tarrhal bronchitis, 467. 

Taste, sense of, in new-born child, 22. 

Teachers, necessity for knowledge of 
child's nervous system by, 6. 

Teeth, care of, 146; Hutchinson's, 146, 
366; imperfection of, in sporadic cre- 
tinism, 554; permanent, 146; syphili- 
tic, 365; temporary, 144.' 

Temperature, of bath in early infancy, 
3; of bath in scarlet fever, 329; of 
cold pack, 405; of incubator, 66; of 
Priessnitz applicator, 451; of sponge 
bath in illness, 45; of tub bath in 
illness, 45, 267; of warm bath in as- 
phyxia neonatorum, 73; of warm bath 
in eclampsia, 682. 

Temperature of room, in acute articu- 
lar rheumatism, 441; in bronchopneu- 
monia, 468; in acute catarrhal bron- 
chitis, 441 ; in acute laryngitis, 443 ; in 
lobar pneumonia, 450; in measles, 
339; in acute nephritis, 581; in scarlet 
fever, 329. 

Temperature, range of, in adenitis, 543; 
in appendicitis, 225; in acute articular 
rheumatism, 403; in brain abscess, 
618; in bronchopneumonia, 457, 458; 
in cholera infantum, 192; in chorea, 
700; in cystopyelitis, 585; in diph- 
theria, 297; in empyema, 472; in acute 
endocarditis, 490; in enteric infection, 
190; in erythema infectiosum, 343; 
in erythema multiforme, 730; in acute 
gastric indigestion, 159; in acute gas- 
tritis, 160; in acute gastroduodenitis, 
165; in gonococcus vulvovaginitis, 
592; in hemophilia, 538; in Hodgkin's 



disease, 541; in Holt's inanition fever, 
88; in influenza, 309, 311; in acute in- 
testinal indigestion, 184; in chronic in- 
testinal indigestion, 199; in intestinal 
intussusception, 221 ; in acute laryn- 
gitis, 430; in lobar pneumonia, 445; 
in lymph-node tuberculosis, 383; in 
malaria, 281; in mastoiditis, 717; in 
measles, uncomplicated, 336; in mea- 
sles, complicated with bronchopneumo- 
nia, 337, 338; in meningococcic men- 
ingitis, 633 ; in mumps, 359 ; in myeli- 
tis, 653; in acute nephritis, 577; in 
otitis media, 714; in pericarditis, 510; 
in peritonitis, 230; in pleurisy, 472; 
in acute anterior poliomyelitis, 644; 
in pseudoleukemia, 525; in purpura 
hemorrhagica, 533; in recurrent vom- 
iting, 253; in retropharyngeal abscess, 
428; chronic rheumatoid arthritis, 
408; in acute rhinitis, 412; in rubella, 
341; in scarlet fever, 318; in sepsis of 
the newborn, 78; in septic endocar- 
ditis, 494; in stomatitis gangrenosa, 
153; in tetanus neonatorum, 90; in 
tetany, 689; in acute follicular ton- 
sillitis, 419; in tuberculous broncho- 
pneumonia, 462; in tuberculous menin- 
gitis, 627; in typhoid fever, 269, 270, 
271, 272; in vaccinia, 352; in variola, 
346; in varicella, 355. 

Temperature, subnormal, in congenital 
atelectasis, 74; in premature infants, 
62; in sporadic cretinism, 554, 555. 

Tenia, 211; diagnosis of, 213; differen- 
tial diagnosis in, 211; elliptica, 213; 
saginata, 211; solium, 211; sympto- 
matology of, 213; treatment of, 214; 
varieties of, 211. 

Testicle, undescended, 297. 

Tetanus, antitoxin of, 59; transmission 
of, by vaccination, 353. 

Tetanus neonatorum, 89; treatment of, 
90. 

Tetany, 686; definition of, 686; differ- 
ential diagnosis in, 689; etiology of, 
686; pathology of, 687; symptomatol- 
ogy of, 687; treatment of, 689. 

Therapeutics of infancy and child- 
hood, 38. 

Thermogenic centers, activity of, in 
young child, 26, 260; loss of restraint 
over, in heat-stroke, 262; situation of, 
25. 

Thermoinhibitory centers, 26; in pre- 
mature infant, 62. 

Thigh friction. See Pseudomasturba- 
tion. 



INDEX 



779 



Thompson's solution of phosphorus, 
245. 

Thompson, on congenital laryngismus 
stridulus, 437. 

Thread worm. See Oxyuris vermicular is. 

Throat and nose, inspection of, in ill- 
ness, 29; daily disinfection of, protec- 
tion against endocarditis, 493. 

Thrush. See Stomatitis aphthosa. 

Thumb-sucking, 703. 

Thymus gland, anatomy of, 545; asth- 
ma associated with enlargement of, 
546; enlargement of, in status lympha- 
ticus, 545, 657, 648; excessive activity 
of, 548; function of, 545; hyperpla- 
sia of, 545; surgical treatment for en- 
largement of, 550; X-ray treatment 
for enlargement of, 548. 

Thyroid gland, absence of, 557; exces- 
sive activity of, 557; excessive activ- 
ity of, at puberty, 17; insufficient ac- 
tivity of, 555; insufficient activity of, 
a cause of enuresis, 599; therapeutic 
use of, 556. 

Thyroid intoxication, 557; treatment 
of, 558. 

Thyroid therapy, 554. 

Tic. See Habit spasm. 

Tinea tonsurans, 733; treatment of, 
734. 

Tongue, appearance of, in scarlet fever, 
321; appearance of, in typhoid fever, 
272, 276; ulceration of, in whooping 
cough, 289; wandering rash of; See 
Geographical tongue. 

Tongue-tie, 156. 

Tonsils, diseased, anatomy involved in, 
417; association of, with chorea, 701; 
association of, with chronic heart dis- 
ease, 503; association of, with leuke- 
mia, 531; association of, with pavor 
nocturnus, 672, 675; association of, 
with status lymphaticus, 545, 547; 
danger from, to health, 415; micro- 
organisms present in, 417; operation 
for removal of, 421; as portals of in- 
fection, 418, 493; removal of, a pro- 
tection against endocarditis, 493; re- 
moval of, a protection against tubercu- 
losis, 395; removal of, in treatment of 
acute rhinitis, 414; removal of, in 
treatment of chronic rhinitis, 415. 

Tonsillitis, acute follicular, 419; 
differential diagnosis of, 420; symp- 
tomatology of, 419; treatment of, 
222. 

Tonsillitis, 418; accompanying ade- 
noid disease, 425; accompanying acute 



articular rheumatism, 404; accompany- 
ing influenza, 310; accompanying acute 
anterior poliomyelitis, 644; diagnosis 
between, and diphtheria, 420; differ- 
ential diagnosis of, 420; acute follicu- 
lar, 418; preceding laryngitis, 430; 
prognosis of, 420; recurrent vomiting 
associated with, 503; acute rhinitis as- 
sociated with, 413; treatment of, 422; 
ulcero-membranous, 419. 

Tonsillar hypertrophy, chronic, 420; 
treatment of, 424. 

Torticollis, intermittent spasmodic, 
283. 

Toxemia, intestinal, in causation of 
fever, 261, 265; constipation associa- 
ted with, in typhoid fever, 272; effects 
of, in diphtheria, 297; effects of, in 
influenza, 310; effects of, in typhoid 
fever, 269. 

Toxic nephritis. See Nephritis. 

Tracheotomy, in edema of larynx, 435; 
for relief of foreign bodies in larynx, 
trachea, or bronchi, 437; in laryngeal 
diphtheria, 305; in acute rhinitis in 
infants, 415; in variola, 349. 

Transfusion of blood, in hemorrhage of 
new-born, 84. 

Trichuris trichiura, 217. 

Tricuspid regurgitation, 502. 

Trudeau, on treatment of localized 
forms of tuberculosis, 58. 

Trousseau, on causes of tetany, 687. 

Trousseau's symptom, 688, 689. 

Tuberculides of skin, 384. 

Tuberculin reactions, conjunctival, 
385; in diagnosis of concealed lymph- 
node tuberculosis, 385; in differential 
diagnosis between tuberculosis and 
Hodgkin's disease, 542; skin, 36; 
value of, at different ages, 400. 

Tubercle bacillus, bacteriology of, 373; 
in pleurisy, 470; in cystopyelitis, 584. 

Tuberculosis, 373; of bones and joints, 
381, 401; climate in treatment of, 396; 
contagiousness of, 373; contraindica- 
tion to nursing infant, 112; cough in, 
383, 389; diagnosis between, and early 
hereditary syphilis, 367; diagnosis be- 
tween, and Hodgkin's disease, 541; 
diagnosis between, and malaria, 284; 
diagnosis between acute miliary, and 
typhoid fever, 275; diet in, 397; drugs 
used in treatment of, 398; etiology of, 
373; exercise in treatment of, 398; ex- 
posure to, 374; fresh air in treatment 
of, 396; guaiacol inunctions in treat- 
ment of, 398; heredity in transmission 



780 



INDEX 



of ; 375; hydrocephalus due to, 619; 
acute infectious diseases a predispos- 
ing cause of, 375; influenza a cause 
of, 315; influenza complicated by, 312; 
intestinal form of, 227, 380; of kid- 
ney, 595; of lungs in older children, 
388, 401; lymph-node form of, 377, 
382; measles complicated by, 337; 
medical treatment of, 398; general mi- 
liary, 381; general miliary in infants, 
387; microorganism in, 373; obscure 
fever due to, 364; pathology of, 377; 
peritonitis due to, 381, 401; physical 
signs in, 384; pleural form of, 379; 
portals of infection in, 374; poverty a 
predisposing cause of, 375; prophylaxis 
of, 393 ; pulmonary form of, 379 ; re- 
moval of cervical glands in, 400; rest 
in treatment of, 398; school infection 
in transmission of, 376; as sequel to 
lobar pneumonia, 448; of serous mem- 
branes, 373; of skin, 384; sources of 
infection in, 373; sputum a source of 
danger in, 373; symptomatology of, 
382; tests for, 36; treatment of, 395; 
vaccination not a means of transmis- 
sion in, 355; whooping-cough compli- 
cated by, 288, 289, 290. 

Tuberculosis of lymph-nodes, cervical 
form of, 400; cervical adenitis in, 
386; diagnosis of, 385; diagnosis be- 
tween, and Hodgkin's disease, 542; 
dyspnea in, 382; dwarfishness in, 383; 
enlargement of external lymph-nodes 
in, 384; gastrointestinal disturbance 
in, 383 ; groups of glands involved in, 
378; malnutrition in, 383; menstrual 
irregularities in, 383; neurotic disease 
suggestive of, 382; pain in side in, 
382; pathology of, 377; physical signs 
of, 384; pressure signs of, 385; pro- 
gressive failure of health in, 382; ra- 
diographic examination in, 385; re- 
moval of glands in, 400; respiratory 
symptoms in, 383; simple anemia sug- 
gestive of, 382; skin manifestations 
of, 384; temperature in, 383; tubercu- 
lin reactions in, 385. 

Tuberculous bronchopneumonia, 387; 
treatment of, 401. 

Tuberculous meningitis. See Menin- 
gitis, tuberculous. 

Turpentine, oil of, inhalations of, in 
treatment of acute rhinitis, 414. 

Typhoid fever, 267; abdominal symp- 
toms in, 271; antityphoid inoculation 
in, 276 ; bacillus of, 267 ; baths in treat- 
ment of, 277; blood changes in, 273; 



"carriers" of, ' 267, 268; complica- 
tions of, 274; definition of, 267; dif- 
ferential diagnosis in, 275; diet in, 
276; drugs used in treatment of, 277, 
278; epistaxis in, 273; etiology of, 
267; exanthem in, 271; "carriers" of, 
267, 268; in fetus, 269; incubation 
period in, 269; intestinal hemorrhage 
in, 272, 278; meningitis in, 640; 
mortality in, 275; method of infec- 
tion in, 268; nervous system in, 272, 
278; in new-born, 269; obscure fever 
due to, 265; pathology of, 268; perfo- 
ration of intestine in, 272; prophy- 
laxis of, 275; prognosis of, 275; re- 
lapses in, 274; removal of patient in, 
279; respiratory symptoms in, 273; 
sources of infection in, 268; splenic 
enlargement in, 271; symptomatology 
of, 269; temperature changes in, 270; 
tongue in, 272; treatment of, 276; 
urine findings in, 273; Widal reaction 
in diagnosis of, 273. 

Typhoid vaccine, therapeutic use of, 59. 

Tyrotoxicon, symptom group produced 
by, 176. 

U 

Ulcer of stomach, 164. 

Umbilical cord, care of, 3. 

Umbilicus, diseases of, 84; gangrene, 
85; hemorrhage, 85; hernia, 86; in- 
fection of stump, 84; vegetations, 84. 

Unguentum crede, therapeutic use of, 
43; in adenitis, 544; in dermatitis ex- 
foliativa of new-born, 80 ; in erysipe- 
las of new-born, 82; in measles, 340; 
in acute infective myelitis, 657; in 
septicemia of diphtheria, 307; in sep- 
ticemia of scarlet fever, 331; in tu- 
berculous peritonitis, 401; in ulcerative 
endocarditis, 494. 

Upper arm paralysis, 99. 

Urea, amount of, in infancy, 561; reten- 
tion of, in acute nephritis, 577. 

Uremia, presence of, in cystic degenera- 
tion of kidney, 589; in acute nephri- 
tis, 576; in tumor of the kidney, 588; 
eclampsia caused by, 680. 

Urethritis, in male child, 595. 

Uric acid, "infarcts," 561. 

Uric acid, in urine, in infancy, 561; in 
acute nephritis, 577; in whooping- 
cough, 290. 

Urine, acidity of, a cause of pseudo-mas- 
turbation, 607, 609; effect of uric acid 
upon, 561; examination of, in illness, 
34; fluctuations in amount of, 560; 



INDEX 



781 



frequency in passage of, 561; incon- 
tinence of, 561; method of collecting 
for examination in infant, 559; reten- 
tion of, in myelitis, 656; suppression 
of, in absence of kidney, 577; suppres- 
sion of, in acute nephritis, 577; sup- 
pression of, in new-born, 561; suppres- 
sion of, in young child, 560. 

Urogenital organs, embryonic develop- 
ment of, 604; nerve supply of, 605; 
physiological evolution of, 605. 

Urotropin, therapeutic use of, in cys- 
tOpyelitis, 587; in enuresis, 603; in 
mumps, 360; in acute anterior polio- 
myelitis, 651. 

Urticaria, 726; accompanying asthma, 
713; characteristic of, 726; definition 
of, 726; diet in, 728; etiology of, 726; 
accompanying Henoch's purpura, 534; 
mucous membranes in, 727; prognosis 
in, 727; accompanying purpura rheu- 
matica, 535; symptomatology of, 726; 
treatment of, 727. 

Uvula, elongated, 155. 



Vaccinia, 349 ; clinical manifestations of, 
351; complications of, 353; definition 
of, 349; incubation period of, 349; 
temperature in, 351; secondary rash 
in, 352. 

Vaccination, discovery of, 349; immun- 
ity, conferred by, 353; technique of, 
350; treatment of wound, 354; virus 
used in, 350. 

Vaccine therapy, 55 ; antiserums in, 59 ; 
autogenous vaccines in, 57; bacterial 
vaccines in, 56; clinical reaction in, 
56; coli vaccines in, 59; in cystopye- 
litis, 587; discovery of, 55; in chronic 
empyema, 481 ; in f uruneulosis, 729 ; 
gonococcus vaccine in, 58; in gono- 
coccus vulvovaginitis, 594; Koch's tu- 
berculin in, 58; in lobar pneumonia, 
452 ; opsonic index in, 56 ; pneumococcus 
vaccine in, 58; rules for use of, 56; 
in scarlet fever, 332; staphylococcus 
vaccine in, 57; streptococcus vaccine 
in, 58; therapeutic indications for, 57; 
typhoid vaccines in, 59; in ulcerative 
endocarditis, 494; in whooping-cough, 
294; without opsonic index, 56. 

Valentine's meat juice, 277. 

Valerian, therapeutic use of, in asthma, 
708; in functional heart disorders, 508. 

Varicella, 354; blood changes in, 356; 
complications in, 356; definition of, 



356; diagnosis of, 354; diet in, 357; 
drugs used in treatment of, 356; en- 
anthem stage in, 355; etiology of, 354; 
exanthem stage in, 356; immunity con- 
ferred by, 357; incubation period in, 
355; microorganisms present in, 354; 
prophylaxis in, 357; quarantine in, 
357; symptomatology of, 355; temper- 
ature changes in, 355; treatment of, 
357. 

Variola, 345; blood changes in, 347; 
clinical forms of, 347; confluent form 
of, 347; contagious period of, 345; 
definition of, 345; diagnosis of, 348; 
diet in, 348; drugs used in treatment 
of, 348, 349; enanthem stage in, 346; 
etiology of, 345; exanthem stage of, 
346; hemorrhagic form of, 347; im- 
munity conferred by, 345; incubation 
period of, 345; invasion stage of, 345; 
microorganisms present in, 345; mor- 
tality from, 350; prophylaxis of, 348; 
purpuric form of, 348; quarantine in, 
348; red light treatment of, 349; 
symptomatology in, 345; temperature 
changes in, 346; transmission of, 345; 
treatment of, 348; urine findings in, 
347; vaccination as protection against, 
349. 

Vasomotor paralysis. See Splanchnic 
paralysis. 

Vaughn, on contaminated food, 176. 

Vegetations of the umbilicus, 84. 

Venesection, therapeutic use of, in 
acute cardiac dilatation, 498; in ec- 
lampsia, 683; in acute nephritis, 580. 

Veronal, therapeutic use of, in chorea, 
701; in meningococcic meningitis, 638; 
in multiple neuritis, 664; in acute ne- 
phritis, 581. 

Villemin, operation by, for obstruction 
of esophagus, 158. 

Vincent's angina. See Ulceromembran- 
ous tonsillitis. 

Vincent's bacillus, 419. 

Vincent's spirillum. See Vincent's 
bacillus. 

Vipond, isolation by, of bacillus produc- 
ing scarlet fever, 317. 

Vleminckx's solution, formula for, 
729. 

Vomiting, as symptom, of brain abscess, 
618; of brain tumor, 618; of enteric 
infection, 191; of intestinal intussus- 
ception, 220; in lobar pneumonia, 44^; 
in malaria, 284; in meningococcic men- 
ingitis, 632; in purulent meningitis, 
639; in recurrent vomiting, 283; in 



782 



INDEX 



scarlet fever, 318; in tuberculous men- 
ingitis, 627. 

Vomiting, recurrent. See Recurrent 
vomiting. 

Von Jaksch, discovery of pseudoleu- 
kemia by, 524. 

Von Jaksch's disease. See Pseudo- 
leukemia. 

Von Noorden, on factors in formation of 
oxybutyric acid, 565. 

Von Pirquet, on predisposing causes of 
tetany, 687; on scarification tuberculin 
test in diagnosis of lymph-node tuber- 
culosis, 385; on skin reaction in tuber- 
culous meningitis, 628, 629. 

Von Pirquet 's test, for tuberculosis, 
35. 

Vovaird, investigation by, on primary 
splenomegaly, 552. 

Vulvovaginitis, gonorrheal, 591; com- 
plications of, 592; definition of, 591; 
epidemics of, 591; etiology of, 591; 
frequency of, 595; microorganisms in, 
592; prognosis of, 593; prophylaxis 
of, 593; sources of infection in, 591; 
symptomatology of, 592; treatment of, 
593; vaccine therapy in, 594. 

Vulvovaginitis, simple, 595; associa- 
tion of, with pseudo-masturbation, 
608. 

Vulva, diphtheria of, 299. 



W 



Walker-Gordon laboratories, 141. 

Walker-Gordon milk, 118. 

Wandering rash of the tongue. See 
Geographical tongue. 

Warthin, on edema of thymus gland, 
545; on weight of thymus gland in 
health and disease, 545. 

Wassermann-Neisser reaction, 362, 
368. 

Water, drinking, in causation of ty- 
phoid fever, 268, 275; importance of, 
in infant diet, 105; importance of, to 
new-born, 113. 

Water, drinking, therapeutic use of, 47; 
in influenza, 313; in lobar pneumonia, 
451 ; in multiple neuritis, 663 ; in 
chronic nephritis, 583; in orthostatic 
albuminuria, 571; in purpura, 536; in 
typhoid fever, 277. 

Weaning, 116. 

Weichselbaum, discovery by, of special 
organism of meningococcic meningitis, 
631. 

Weight, comparative ratio of, in boys 



and girls, 16, 17; gain in, during first 
year of life, 15; gain in, after first 
year of life, 15 ; importance of ascer- 
taining, at first examination in illness, 
29; importance of, to health, in infan- 
cy and childhood, 13 ; premature in- 
fants deficient in, 65; relation of, to 
physical condition, 7; relation of, to 
skin surface of body, 26; significance 
of failure to gain in, 14. 

Welsh, E. J., method of injecting blood 
serum introduced by, 84. 

Wet nurse, advantages of, 117; in gas- 
trointestinal disorders, 74; in enteric 
infection, 194; for premature infant, 
68; in pseudo-leukemia, 526. 

Wet nurse, danger to, of syphilitic in- 
fant, 369; of tuberculous infant, 394. 

Whey, as artificial food in chronic intes- 
tinal indigestion, 201; proteins con- 
tained in, 101. 

Whiskey, therapeutic use of, in broncho- 
pneumonia, 466; in acute cardiac dila- 
tation, 498; in diphtheria, 307; in en- 
teric infection, 193; in lobar pneu- 
monia, 450, 453; in new-born, 73, 81; 
in acute pericarditis, 513; in pleurisy, 
478; in acute anterior poliomyelitis, 
651; in scarlet fever, 329; in typhoid 
fever, 277, 278; in variola, 349. 

Whooping-cough, 287; bacillus of, 287; 
blood changes in, 289; catarrhal stage 
in, 288; complications of, 290; con- 
tagious period in, 288; course of, 290; 
acute catarrhal dilatation caused by, 
496, 497; danger of, to infants, 6; 
danger of, to tuberculous children, 
395; definition of, 287; diagnosis of, 
290; diet in, 292; drugs used in treat- 
ment of, 293; etiology, 287; incuba- 
tion period of, 288; measles complica- 
ted by, 338 ; medical treatment of, 
293 ; prognosis of, 291 ; prophylaxis in, 
291; psychic treatment of, 292; spas- 
modic stage of, 288; symptomatology 
of, 288; temperature changes in, 288; 
treatment of, 291; urine findings in, 
290. 

Wickman, on mortality in acute anterior 
poliomyelitis, 650; on types of acute 
anterior poliomyelitis, 644. 

Widal reaction. See Gruber-Widal re- 
action. 

Williams, on thyroid insufficiency as a 
cause of enuresis, 599; on thyroid ther- 
apy in enuresis, 603. 

Winckel's disease. See Epidemic he- 
moglobinuria. 



INDEX 783 

WiNTEKGREEN, oil of, therapeutic use of, Z 

by inunction, 42, 43; in acute folli- 
cular tonsillitis, 422. Zinc, multiple neuritis due to poisoning 
Wollstein, observations by, on bacillus by, 661. 

pertussis, 287. Zinc oxid, therapeutic use of, internally 

Wright, E. A., on antityphoid inocula- in tuberculous diarrhea, 400. 

tion, 276; on "opsonins," 55, 56. Zinc oxid, ointment of, therapeutic use 

"Wrist-drop," 662. of, in eczema, 723, in erythema multi- 

forme, 730; in syphilis, 373. 
X Zinc stearate, therapeutic use of, in ec- 

zema, 723; in pemphigus neonatorum, 
X-ray. See Bontgen rays. 733. 



(1) 



51 



r 



OCT 11 1912 



